Friday, June 22, 2018

Civil Society and Doctor-Patient Sex

On June 4 the Boston Globe reported that for two years the Massachusetts Board of Registration of Psychologists had taken no action on Ms. Lisa Grover's complaint of abuse by her therapist, Dr. Mel Rabin. In a subsequent article the Boston Globe told readers that the next day Dr. Rabin surrendered his license, "acknowledging that he put the patient 'at risk of harm' and failed to maintain professional boundaries." In response to Dr. Rabin's letter the Board revoked his license, information that can be found on its website.

In cases with allegations as serious and believable as those brought forward by Ms. Grover, a professional board must act, as by suspending the practitioner's license while the case is investigated, by requiring monitoring of the practice, or some other way of protecting the public. Failing to act invites public distrust of the regulatory process and of the profession itself, and exposes the public to avoidable risks. In Dr. Rabin's case the media report accomplished what the Board of Registration should have done two years earlier.
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 After I published my initial post on the situation I spoke with Ms. Grover. Our conversation highlighted two additional issues - the mysterious sources of resilience and the power of peer support.

When Ms. Grover came to see her relationship with Dr. Rabin as exploitative, she determined to land on her feet and to do all she could to protect others from comparable abuse. She's not clear where her strength came from. Her family was supportive, but there was also an internal resolve to speak out. It's not uncommon for legal settlements to include a gag order, under which the complainant agrees not to speak in public about the situation in return for the financial agreement. Ms. Grover refused to accept any such requirement.

She made her way to the TELL (Therapy Exploitation Link Line) website where she "met" others struggling with their own experiences of abuse. Meeting peers strengthened her resolve and sharpened her sense of how to take effective action on behalf of others and for her own healing. She is working with other volunteers to respond to the 40,000 hits TELL receives each year.

 In Ms. Grover's situation, government regulation (the psychology licensing board) failed, but civil society - in the form of the press (the two  Boston Globe articles) and peer support (TELL) - came though. Dr. Rabin did not govern himself by the ethics of his profession, and the licensing board was dilatory in its response, but resilience, the press and peer support helped Ms. Grover move from victimization to effective advocacy.

Monday, June 4, 2018

Doctor-patient sex and professional self-regulation

The topic that has attracted the largest readership on this blog is doctor-patient sex. In the past 10 years the 30 posts I've written on the topic have received 75,000 hits. An article in today's Boston Globe focuses on an aspect I've discussed only briefly thus far - professional self regulation.

The story concerns a complaint from Ms. Lisa Grover that Dr. Melvin Rabin, the psychologist she sought out when her marriage broke up, drew her into a sexual relationship. Grover's allegations dramatize the way "boundary crossings" like calling the patient at home "just to talk," calling the patient a "special person," and hugging at the end of the appointment, can lead, over time, to "boundary violations" like sex. Apparently Grover brought a malpractice action against Rabin which, the article reports, was "settled for an undisclosed sum."

In February 2016 Grover complained to the Massachusetts Board of Registration of Psychologists, but the case is still "open" and Dr. Rabin's license is still unrestricted.

A core component of the implicit contract between the health professions and society is that in exchange for the autonomy and trust society gives to the professions, the professions will regulate themselves with regard to quality and integrity. Two years is much too long for a professional board to leave a serious complaint like Ms. Grover's unsettled.

In dealing with complaints of the kind Ms. Grover brought, a board must consider three values:

First and foremost, safety for patients. If the board believes Ms. Grover's accusations, it should have suspended Dr. Rabin's license. A therapist who acted as Ms. Grover describes should not have an unrestricted license, which allows unrestricted, unmonitored access to patients. What Ms. Grover describes, if true, is very serious misconduct.

But second, a board must also recognize that complaints are not necessarily true. The board must consider fairness to the accused.

I know this first hand.When I joined the Harvard Community Health Plan practice in 1975, one of my first patients was a sensitive and vulnerable young woman with a mild autism spectrum disorder. The treatment was proceeding well until I cancelled an appointment because I was going away. My patient contacted the psychiatry board to complain that I had molested her. Psychologically my cancellation felt to her like a "molestation." By the time I heard from the board my patient and I had resumed meeting and the treatment was again on track. She explained that she had been upset by the cancellation and apologized for what she said to the board. I didn't appreciate at the time just how serious a threat a false accusation could be.

To the credit of the Boston Globe, the headline to the article refers to an "alleged betrayal." But if the Board does not believe Ms. Grover, it should have closed the case by now. Two years is too long for the case to be in limbo. A false accusation is a serious injury to the clinician.

Finally, a professional board should conduct itself in a way that fosters trust in the profession. The story reported in the Boston Globe does the opposite.

(In addition to the Boston Globe article describing Ms. Grover's allegation, readers may be interested in an interview with Dr. Rabin in which he describes himself and his approach to therapy.)

Wednesday, May 30, 2018

Loneliness and Health


It's easy to make jokes about the British "Minister of Loneliness," as Steven Colbert did when Theresa May announced creation of the new position this winter. But for several decades we've known that loneliness isn't a joke - it's a significant risk factor for poor health and premature death.

Here's how Vivek Murthy, the former Surgeon General, explains the health impact of loneliness:

...Over thousands of years, the value of social connection has become baked into our nervous system such that the absence of such a protective force creates a stress state in the body. Loneliness causes stress, and long-term or chronic stress leads to more frequent elevations of a key stress hormone, cortisol. It is also linked to higher levels of inflammation in the body. This in turn damages blood vessels and other tissues, increasing the risk of heart disease, diabetes, joint disease, depression, obesity, and premature death.

Understanding the toxicity of loneliness has implications for public policy and health care practice. The UK ministry exemplifies a public policy action. But my interest for this post is health care.

Physicians are overburdened with requirements, but asking about our patients' social connectedness is central to understanding them. Loneliness is often the result of illness. People who are ill may withdraw from the social world, and sometimes others may withdraw from them. And loneliness can cause vulnerability to illness and diminish the resilience we need to recover.

In my psychiatric practice I sometimes took out my prescription pad and wrote instructions like "talk with a friend at least once every day" to dramatize my belief that in many circumstances, persons could be more effective than pills. And I kept a file with resources patients mentioned: AA and NA groups, Alliance for the Mentally Ill support programs, and more. Over time this helped me suggest venues that aligned with my patients' temperaments for those who might benefit from the right kind of peer support.

When I was asked to start an HMO outpatient program for patients with chronic mental illness I surveyed the literature for guidance. While the term "loneliness" wasn't used, the most promising models were group-based programs with an informal, friendly and welcoming atmosphere. For several years I had the privilege of being the psychiatrist who met with the group. Patients could come as often or as rarely as they wished. When a patient had a question about medication of some other aspect of treatment, I could usually direct the question to another patient with first hand experience of the treatment in question. Patients often became friends.

The widening recognition of loneliness as a toxic state and meaningful social connection as a health promoting factor is a positive step for health care. But, unfortunately, valuable insights can be drowned in bureaucratic regulations. Reducing inquiry about loneliness to a required checklist of questions risks coming across to patients as sterile and perfunctory, and to physicians as one more requirement in the ever-lengthening list of externally driven expectations.

But when interest in the social texture of our patients' lives is part of the clinician and patient coming to know each other as human beings and collaborating in service of health, both parties will gain.



Monday, January 8, 2018

Hiatus

Dear Readers
This is a belated post to explain that I'm taking a hiatus from the blog. My plate has been rather full in recent months and there have been some health matters to deal with. I look forward to returning to regular posting in the spring.
Best to all
Jim