Total Risk Management

Martin H. Williams, Ph.D.

I recently was fortunate enough to obtain Gutheil and Gabbard's 1993 article in the American Journal of Psychiatry. The article, entitled "The Concept Of Boundaries In Clinical Practice: Theoretical And Risk-Management Dimensions," opened my eyes to the type of legal exposure I face in my practice. One point that Gutheil and Gabbard make is that certain things that psychotherapists do, which are perfectly innocent and legitimate, may appear to be shady in court. The idea here is that innocent therapists sometimes get sued, even if they fully comply with and support the ethics guidelines of their professions. If you ever do get wrongfully sued, you would be much better off not to have done any of these risky behaviors, as they simply provide ammunition for the plaintiff.

Although I recognize the seriousness of the issue of therapist-abuse of patients and of boundary violations, I hadn't realized that even perfectly innocent aspects of practice could get a therapist in trouble. Consider this: Therapists who become sexually involved with their patients, often schedule that patient to be the last one of the day. This blurs the "boundary" between the therapeutic and the social, especially when the sessions get lengthy (see below). Gutheil and Gabbard cite cases in which the plaintiff's status as the last patient of the day was used in court to support claims of therapist-abuse.

Then, there is the matter of hugging. I know that many psychologists hug their patients. Nevertheless, Gutheil and Gabbard tell us that it can be difficult for a jury to believe that something inappropriate didn't take place during the session if there had been a hug before and after. In addition, self-disclosure is a problem. It seems that plaintiffs' attorneys have been rather successful at convincing juries that patients who know a lot of details about the psychotherapist's life had probably been sexually intimate with them. To quote that great essayist, Dave Barry, "I am not making this up."

The bottom line, according to these authors, is that innocent psychotherapists, wrongly accused, might nevertheless lose malpractice cases or licensing board actions based on the mere appearance of misconduct.

Not to take this kind of risk exposure sitting down, I have instituted certain changes in my practice style which I am willing to share freely. I call it, "Total Risk Management." Please feel free to take notes.

1. To absolutely prevent the boundary violation by which the patient addresses me by my first name, thereby starting on the slippery slope towards the appearance of sexual intimacy, I have taken a razor blade and cut my first name off of my diplomas and my license that hang in my office. This was no picnic, as my mother once had some of my degrees Perma-Plaqued, which meant I needed a mallet and chisel to remove the potentially dangerous "Martin." I did the same for my business cards, which required patience, as I had just received a shipment of 1000 of them. But, better to be safe then sorry. After reading Gutheil and Gabbard, I can mentally hear the plaintiff's attorney saying to the jury, "And what do you think it means that the patient knew the doctor's first name? Do you suppose this is just some innocent form of humanistic therapy? Of course not. They were obviously sexually intimate. Ladies and gentlemen of the jury, if this is not proof, then I don't know what is!"

I looked at my office floor, covered as it was with over a thousand little "Martins," relaxed for a minute, but then I recalled that back when I was in the Navy, I got my first name tattooed on my arm. I immediately scheduled some risk-management plastic surgery. On the way home from the plastic surgeon, I remembered that back in the 1950's, J. Edgar Hoover had come out with a report on motorcycle gangs. The report concluded that only 1% of motorcyclists are outlaws. At the time, many defiant bikers began wearing emblems that said simply, "1%," to show the world that sticks and stones will break their bones, but names will never hurt them. This inspired me. I recalled findings that showed that around 10% of therapists had been sexually involved with their patients. The risk-management solution was obvious: As soon as my arm had healed, I went to a tattoo parlor and got one that said simply "90%" to send a clear risk-management message about where I stand.

2. Gutheil and Gabbard make clear that failing to set time limits on sessions is also one of those boundary violations that can proceed to a complete breakdown of the therapy into a social relationship. I don't want any jury hearing that kind of stuff about me, but what I don't know is how accurate I need to be about the time boundary. Obviously, a two or three hour session begins to look like I've lost control of therapy, but is five extra minutes OK? What about two?

I didn't sleep last night as I worried about how to manage this risk, but then I had a brainstorm. I jumped out of bed and built a time-boundary-management-device, connecting the patient's chair, an electric dog collar, the office door, the clock and various pieces of assorted hardware. Now, when the fifty-minute session is over, the patient automatically receives a small electric shock from the dog training device and the office door automatically springs open. What could be a clearer message that the time boundary is being properly maintained? I may even add an illuminated sign that says, "Session over. Have a nice day."

One advantage of the time-boundary-management-device is that it is objective, thereby protecting me from allegations that I unconsciously acted out with an attractive patient by reliably allocating him or her several extra seconds of treatment. How would it look at a hearing if the licensing board assigns an investigator to time my sessions with a stopwatch, and it turns out that I'm acting out around time and don't even know it?

3. Hugging is the final frontier of my Total Risk Management approach. Gutheil and Gabbard describe a physical maneuver that involves grabbing and holding the hands of any patient who proves to be an aggressive hugger (see above regarding that I am not making this up). That is all well and good until the patient sues you for injuries pertaining to the struggle over the hug. What is needed is something that is both less ambiguous and more reliable. This took some work, but I just installed my anti-hugging management system. It involves a glass wall between myself and the patient. We can have the human contact of seeing each other, but touching becomes absolutely impossible. I felt completely vindicated--in advance of any allegations--until I noticed that I couldn't hear very well through the glass. Fortunately, the Jack-in-the-Box down the street was being remodeled, and I got my hands on the communication device from the drive-through window. Now I just say to my patients, "Speak into the clown."

I'd like to write more, but I need to contact the APA Insurance Trust. "To Whom It May Concern. Please consider reducing my malpractice premium for the following reasons....."