Treating Professionals Handout SASH 2007

Treating Health-Care and Legal Professionals with Sexual Disorders: A values-based approach: 

Treating Health-Care and Legal Professionals with Sexual Disorders: A values-based approach Philip Hemphill, LCSW Program Director Professional Enhancement Program

Introducing Neuro-linguistic Programming (O’Connor, 2001): 

Introducing Neuro-linguistic Programming (O’Connor, 2001) ‘Pure experience has no meaning. It just is. We give it meaning according to our beliefs, values, preconceptions, likes, and dislikes. The meaning of an experience is dependent on the context. Reframing is changing the way you perceive an event and so changing the meaning. When the meaning changes, responses and behaviour will also change.’

OBJECTIVES: 

OBJECTIVES To understand personal and social issues impacting professionals with sexually aberrant behavior To identify and review data on professionals with co-morbid disorders To clarify the integration of a values-based model and techniques for intervention with professionals

Characteristics of Professionals: 

Characteristics of Professionals External rewards Esteem, status, privilege, power, income Internal rewards Legacy of relationships, service to others, choosing one’s vocation Self-efficacy and ability to be goal-directed Capacity of endurance Sense of responsibility Intellectual abilities Help others

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Decision making is influenced by personal psychological factors and cultural factors. Many professionals have an authoritarian style with rigidity, inflexibility, and need for highly predictable environment. There is a strong drive for achievement and a fear of failure. These types in general may respond to stress with an attempt to regain control, though by outwardly behaving as though everything is normal, internally and externally.

Special. Relating to or designating a species, kind, individual, thing, or sort; designed for a particular purpose; confined to a particular purpose, object, person, or class.: 

Special. Relating to or designating a species, kind, individual, thing, or sort; designed for a particular purpose; confined to a particular purpose, object, person, or class.

Failure = Lack of effort: 

Failure = Lack of effort Inability to ask for or receive help

Problems in Professional Training and Practice: 

Problems in Professional Training and Practice Extreme competition Social isolation Sleep deprivation Pressure to excel Self-neglect Cynicism Family discord Expectations of perfection Conflict of values Difficult decisions Lack of limits Suppressed emotions Operating a business Living up to the position Lack of balance Adversarial nature of the work

200 Attorneys Studied: 

200 Attorneys Studied 1/3 = completely or quite satisfied 1/3 = somewhat satisfied 1/3 = not satisfied 35% unsure or definitely want to leave law 70% in California poll would start a new career if possible

Depression in Attorneys: 

Depression in Attorneys 10% prevalence of Major Depression > twice that of the general population Applicants = general population End of first year, 32% depressed End of third year, 40% depressed Two years of practice, 17% -20% depressed, 12% problem drinkers, 6% both 33% in practice in Washington with depression, problem drinking, or cocaine abuse

Indicators of Problems in Lawyers: 

Indicators of Problems in Lawyers Being late for court Failing to file legal notifications Poor records Misappropriating funds Delays in taking care of mail Missing deadlines Failing to return calls Intentionally failing to pursue lawful objectives

Physician Burnout(Gunderson, 2001;Chopra et.al., 2004; Williams, 2002): 

Physician Burnout (Gunderson, 2001;Chopra et.al., 2004; Williams, 2002) “If you don’t care, you won’t get exhausted” Lack of perceived control is the best predictor of burnout 44% male and 26% female reported being very satisfied with their individual practices 40% reported feelings of stress and burnout 93% increased paperwork ; 70% pessimistic about future “more emphasis has been placed on making sure that you document a visit than on the quality of the encounter” 73% daily pt contact as most rewarding aspect of practice 8-12% of health professionals develop substance-related disorder “code of silence” and reluctant to police themselves

Physician Burnout(Gunderson, 2001;Chopra et.al., 2004; Williams, 2002): 

Physician Burnout (Gunderson, 2001;Chopra et.al., 2004; Williams, 2002) Male physicians are two times more likely to commit suicide than average Americans Females physicians are three times more likely Symptoms Exhaustion Depersonalization Diminished personal feelings of personal accomplishment A twenty-five year prospective study showed that burnout is not associated with hours worked, income, practice arrangement, or specialty but rather with personality profile and perceived stress at work.

Stress: 

Stress The discrepancy between the demands of a situation and the capacity of the individual or group to deal with it comfortably.

Causes of Stress: 

Causes of Stress Increased workload Decreased autonomy A sense of loss of control Pressure to increase productivity and quality while reducing costs Inability to balance obligations

External Stressors: 

External Stressors Conflict with others Demands for performance The more threatening the stressor is perceived, the more stress it creates.

Internal Stressors: 

Internal Stressors Intolerance of one’s own mistakes Unrealistic expectations of others Worry about things one cannot control

Slide18: 

Primum Non Nocere

The Hippocratic Curse: 

The Hippocratic Curse ‘While I continue to keep this oath unviolated, may it be granted to me to enjoy life and the practice of the art, respected by all men, in all times! But should I trespass and violate this Oath, may the reverse be my lot!’

The Pendulum Swings (M.D.s): 

The Pendulum Swings (M.D.s) APA condemned sex with patients-73’ APA added former patients – 89’ AMA condemned sex with patients-86’ AMA added most former pts.-92’ If physician “uses or exploits trust, knowledge, emotions, or influence derived from the current or previous professional relationship.”

Code of medical ethics of the American Medical Association (2001 revision: section 8.14): 

Code of medical ethics of the American Medical Association (2001 revision: section 8.14) ‘Sexual contact that occurs concurrent with the physician–patient relationship constitutes sexual misconduct. Sexual or romantic interactions between physicians and patients distract from the goals of the physician–patient relationship, may exploit the vulnerability of the patient, may obscure the physician’s objective judgment concerning the patient’s healthcare, and ultimately may be detrimental to the patient’s well-being. Sexual or romantic relationships between a physician and a former patient may be unduly influenced by the previous physician–patient relationship. Sexual or romantic relationship with former patients are unethical if the physician uses or exploits trust, knowledge, emotions or influence derived from the previous professional relationship.’

FSMB Definition of PSM: 

FSMB Definition of PSM “Behavior that exploits the physician-patient relationship in a sexual way. This behavior is non-diagnostic and non-therapeutic, may be verbal or physical, and may include expressions of thoughts and feelings or gestures that are sexual or that reasonably may be construed by a patient or patient surrogate as sexual”

Patient Surrogates: 

Patient Surrogates “those individuals closely involved in the patients’ medical decision-making and care and include (1) spouses or partners (2) parents (3) guardians, and/or (4) other individuals involved in the care of and/or decision-making for the patient.” FSMB

Potential non-sexual boundary violationsGutheil, T. G. & Gabbard, G. O. (1993) The concept of boundaries in clinical practice: theoretical and risk-management dimensions. American Journal of Psychiatry, 150, 188–196: 

Potential non-sexual boundary violations Gutheil, T. G. & Gabbard, G. O. (1993) The concept of boundaries in clinical practice: theoretical and risk-management dimensions. American Journal of Psychiatry, 150, 188–196 Excessive self-disclosure Special fee arrangements (low or free) Extending time beyond what was initially agreed Allowing telephone calls between sessions Extra-therapeutic business relationships Socializing with the patient Calling each other by first name Treating the patient as a friend or confidant/e Touching or frequent hugs

Research suggest that most experience, at least occasional, sexual attraction to those who come to them for professional help and that simply being attracted without acting on it tends to evoke guilt, anxiety, and confusion. (Pope, Keith-Spiegal, & Tabachnick, 1986): 

Research suggest that most experience, at least occasional, sexual attraction to those who come to them for professional help and that simply being attracted without acting on it tends to evoke guilt, anxiety, and confusion. (Pope, Keith-Spiegal, & Tabachnick, 1986)

Various mechanisms postulated in boundary violationsGabbard, G. O. (1994) Psychotherapists who transgress sexual boundaries with patients. Bulletin of the Menninger Clinic, 58, 124–135.[Medline]: 

Various mechanisms postulated in boundary violations Gabbard, G. O. (1994) Psychotherapists who transgress sexual boundaries with patients. Bulletin of the Menninger Clinic, 58, 124–135.[Medline] Mismanaged transference Unconscious re-enactment of incestuous fantasy Rescue fantasy Counter-transference frustration Rebellion against archaic institutional rules ‘Manic defense’ against mourning of termination Exception fantasy Masochistic surrender Projective identification ‘Settling down the rowdy man’

At Personal Risk (Marilyn Peterson, 1992): 

At Personal Risk (Marilyn Peterson, 1992) “Boundaries protect the space that exist between professional and client by controlling the power differential in the relationship.”

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“[S]exual appetite is abnormally increased to such an extent that it permeates all his thoughts and feelings, allowing of no other aims in life, tumultuously, and in a rut-like fashion demanding gratification without granting the possibility of moral and righteous counter-presentations, and resolving itself into an impulsive insatiable, succession of sexual enjoyments… This pathological sexuality is a dreadful scourge for its victim, for he is in constant danger of violating the laws of the state and of morality, of losing his honor, his freedom and even his life.” Krafft-Ebbing (1886)

Residency Restrictions in 23 States: 

Residency Restrictions in 23 States Illinois – 500 ft. Iowa City Miami Beach Texas – 1000 ft. Missouri New Jersey New York Illinois Louisiana Michigan West Virginia Washington Tennessee South Dakota Oklahoma Oregon Indiana Georgia Kentucky California Arkansas Ohio Alabama

Ohio, 2005: 

Ohio, 2005 HB 217 - Sex offender license plates shall have a distinctive pink background color and carry a special serial number that is readily identified by law enforcement officers. The registrar of motor vehicles shall designate the distinctive pink color and serial number to be used on sex offender license plates, which shall remain the same from year to year and shall not be displayed on any other motor vehicles.

2006: 

2006 Following hurricane Katrina, a Louisiana law was enacted to require that sex offenders who enter a shelter during an emergency notify management of their status within 24 hours. It also requires sex offenders who are temporarily displaced or absent from their last address to notify the chief of police in their new location.

Halloween 2006, paroled sex offenders face added restrictions in some states: 

Halloween 2006, paroled sex offenders face added restrictions in some states

Sexual Abuse – An Intimate Crime: 

Sexual Abuse – An Intimate Crime 66% of victims knew the offender as an acquaintance, friend, relative, or intimate 93% of CSA victims knew the perpetrator 34.2% were family members 58.7% were acquaintances Between 10% and 14% of rapes occur within marriage or other cohabiting relationships The closer the relationship, the less likely the assault will be reported

How Our SO Policy is Created: 

How Our SO Policy is Created Many…images [of SOs] reflect basic myths and misconceptions surrounding sex offending that derive from…media stereotypes of sensationalized and exceptional cases. …these social constructions and images of [SOs] often form the basis of criminal law and public policy to control these offenders. In fact, these stereotypical images have been shown by several researchers to have serious negative consequences for the effective detection, treatment, and control of sex offenders. - Miethe et al., Specialization and Persistence in the Arrest Histories of Sex Offenders: A Comparative Analysis of Alternative Measures and Offense Types

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Crimes Against Children Research Center, University New Hampshire David Finkelhor and Lisa M. Jones

Slide37: 

DOJ National Crime Victimization Survey - 2004

Limitations of Current Laws: 

Limitations of Current Laws Focus on stranger-perpetrated offenses, yet most people who perpetrate are Known to the victim/family/community Often loved by the victim/family/community Children dependent on the perpetrator Intimate partners

Limitations of Current Laws: 

Limitations of Current Laws Address convicted sex offenders while the vast majority of SOs are never reported, tried and/or convicted Most incarcerated SOs are “in” for their first conviction

Three Levels of GLM (Ward,2006): 

Three Levels of GLM (Ward,2006) A set of general principles and assumptions that specify the values that underlying rehabilitation practice and the kind of overall aims that clinicians should be striving for The implications of these general assumptions for explaining and understanding sexually aberrant behavior and its functions The treatment implications of a focus on goals (goods), self-regulation strategies, and ecological variables.

The GLM is an example of a Positive Psychological Approach: 

The GLM is an example of a Positive Psychological Approach Primary goods are states of affairs, states of mind, personal characteristics, activities, or experiences that are sought for their own sake and are likely to increase psychological well-being if achieved (Kekes, 1989 and Ward and Stewart, 2003a). The psychological, biological, and anthropological research literature indicates that there are at least ten groups of primary human goods: Life (including healthy living and functioning) Knowledge Excellence in play and work (including mastery experiences) Excellence in agency (i.e., autonomy and self-directedness) Inner peace (i.e., freedom from emotional turmoil and stress) Friendship (including intimate, romantic, and family relationships) Community Spirituality (in the broad sense of finding meaning and purpose in life) Happiness Creativity

Mental Health Themes (Jensen and Bergin, 1985; 1988) : 

Mental Health Themes (Jensen and Bergin, 1985; 1988) Competent perception and expression of feelings Freedom/autonomy/responsibi Integration, coping and work Self-awareness growth Human relatedness/inter-personal and family commitment Self-maintenance/physical fitness Mature values Forgiveness Regulated sexual fulfillment Spiritual/religiosity Freedom, responsibility and self-regulation Love and relationships Identity Truth Values Symptom management Work

Good Lives Model: 

Good Lives Model It is an important emphasis on the construct of personal identity and its relationship to understanding what constitutes a good life. Individuals' conceptions of themselves directly arise from their basic value commitments to pursue human goods, which are expressed in their daily activities and lifestyle. People acquire a sense of who they are and what really matters from what they do; their actions are suffused with values. What this means for therapists is that it is not enough to simply equip individuals with skills to control or manage their risk factors, it is imperative that we are also give the opportunity to fashion a more adaptive personal identity, one that bestows a sense of meaning and fulfillment (Maruna, 2001).

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Finally, according to the GLM, a treatment plan should be explicitly constructed in the form of a good lives conceptualization. An important aspect of this process is respecting the individual's capacity to make certain decisions himself, and in this sense, accepting his status as an autonomous individual. This is in direct contrast to previous recommended practice in the treatment, where therapists were cautioned not to allow patients to participate in decision making. This allows each individual's preference for certain primary goods to be noted and translated into a daily routine (e.g., the kind of works, education and further training, and types of relationships identified and selected to achieve primary goods).

Slide45: 

Rehabilitation is a value laden process and involves a variety of different types of values including: prudential values (what is in the best interests of …) ethical values (what is in the best interests of community) epistemic or knowledge related values (what are our best practice models and methods)

Slide46: 

Value - A principle, standard, or quality considered worthwhile or desirable. Values provide guidance to help us set priorities and make decisions. Moral - Of or concerned with the judgment principles of right and wrong in relation to human action and character. The American Heritage Dictionary

Slide47: 

Values allow us to: Live in harmony within ourselves Live in relationship with others and our world Guide us deeper into our spiritual journeys

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Requirements: Dedicated effort to knowing oneself: Psychologically, Physically and Spiritually Questioning the function of ones thoughts, feelings, and actions Understanding why one does what he/she does at any given moment i.e., motivation, intent Barriers to awareness Habits Robotic living Sequestering undesirable internal parts Denial or avoidance of emotions and thoughts Fear Awareness leads to: Insight Creativity Congruity Conscious living Choice Freedom

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Open, honest, direct communication Respect for self and others Responsibility for one’s choices Accountability for one’s choices and willingness to hold others accountable Inclusion of all parts of self and others

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Open To make known, reveal, or disclose Open communication does not allow for hidden agendas Active listening to self and others Honest Integrity - communicating what you mean and meaning what you communicate Acting from conviction Genuine Direct Addressing issues with the appropriate person Avoiding ambiguity and insinuation Clarity

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Self: Nutrition Sleep Exercise Balance Healthy Relationships Recognizing and using one’s gifts Connecting with one’s individual purpose

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Others: Punctuality Accessibility Completing work in a timely manner Follow-through Maintenance of confidentiality Honoring the boundaries of others Recognizing others as having something unique to contribute regardless of power differential.

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Ability to choose one’s response to any situation Life satisfaction Silence as choice Victimization is incompatible with responsibility

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Recognize Options Rescuers react out of guilt Taking responsibility for one’s choices Critics react out of anger Hold others accountable Victims act out of hurt feelings Addict

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Openness to feedback Soliciting feedback Recognition that one’s choices impact others Admitting what you do not know Acknowledging mistakes Willingness to learn from others Willingness to directly hold others accountable

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Race, religion, sexual orientation, gender Professional roles -- position Socioeconomic status Educational level Different points of view, diverse ideas

Slide57: 

Culture is the totality of socially transmitted behavior patterns, arts, beliefs, institutions, and all other products of human work and thought characteristic of a community or population. The American Heritage Dictionary

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“Spirituality is a commitment to chose, as the primary context for understanding and acting, one’s relatedness to all that is. With this commitment, one attempts to stay focused on relationships between oneself and other people, the physical environment, one’s heritage and traditions, one’s body, one’s ancestors, saints, Higher Power, or God.” Encountering the Sacred in Psychotherapy

Professional Enhancement Program Data (n=32): 

Professional Enhancement Program Data (n=32) Age of clients ranges from 25 to 64, with an average age of 46.24. Average GAF at admission is 50.64. Average GAF at discharge is 63.68. Length of stay ranges from 16 to 120 days (range = 104). Average is 54.4 days.

Professional Enhancement Program: 

Professional Enhancement Program Admission Substance Abuse/Dependence: 16 (64%) MDD/MD Episodes: 8 (32%) Dysthymia: 5 (20%) Bipolar: 1 (4%) Cyclothymia: 1 (4%) MD NOS: 1 (4%) DD NOS: 1 (4%) GAD: 2 (8%) AD NOS: 2 (8%) PTSD: 2 (8%) Psychosis NOS: 1 (4%) ADHD: 1 (4%) Partner relational issues: 2 (8%) Pathological gambling: 1 (4%)

Professional Enhancement Program: 

Professional Enhancement Program 19 (76%) PDNOS w/ various features. The number of people diagnosed with PDNOS with each of the following traits is listed below. There is considerable overlap because the vast majority had more than 1 trait listed: Dependent 4 Aggressive 1 Depressive 4 Sadistic 1 Narcissistic 9 Schizoid 4 Histrionic 1 Avoidant 5 Borderline 3 Passive Agg 3 Self-defeating 3 OC 1 Antisocial 10

Open, Honest, and Direct Communication: 

Open, Honest, and Direct Communication Develop Treatment Plan- Self, Peer, Staff 1st Step work – Journal Writing, Sexual Timeline, Boundary Timeline Communications / Assertiveness / Interpretation of Transference Community – Social Skills development Workbook – Bibliotherapy – DBT Facing the Shadow and Gentle Path (Carnes) Disclosure with Boundaries Family Therapy

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Who? What? Where? When? Why?

Respect: 

Respect Psychodrama – ‘the addict’ EMDR Social Skills – Values Self-Care Contracts / Boundaries Hygiene / Intimacy Fears

The Transforming Power of Affect(Diana Fosha, 2000): 

The Transforming Power of Affect (Diana Fosha, 2000) Therapist must: be emotionally engaged willing to share in affective experiences that are being worked through have access to but not overwhelmed by the intensity of emotional states attend to own experience while focusing on the client be able to fluidly move between the two model how to manage affect have the courage to acknowledge and process our lapses and tolerate the intense affects that come in the wake of processing therapeutic ruptures be able to tolerate the positive affects of repair which is sometimes as hard as tolerating the negative affects of disruption

Responsibility: 

Responsibility Balanced Living Relapse Prevention Plan Vocational PEP Care-360 Monitoring Anger Work Grief Work Core Belief – Masculinity / Femininity Wise Mind

Accountability: 

Accountability 12 Step Meetings Covert Sensitization, Deviant Arousal Family Therapy- Assertiveness Consequences to All Systems Urge Card Lapse Inventory 360° Treatment Plan Medication Management Explore and Accept Cognitive Distortions

Sexual Impropriety Discipline Considerations: 

Sexual Impropriety Discipline Considerations Type of patient harm Severity of offense Accountability of doctor Type of setting Length of termination of Doctor-Pt. Discovery of Offense Age of patients Number of episodes Number of patients Length of relationship (i.e., Opportunistic, Grooming) Formal Eval/Rec. results

(Gechtman,1989; Pope, 1993): 

(Gechtman,1989; Pope, 1993) Learn to identify erotic feelings when they arise and how to use them constructively Seek professional support when experiencing personal loss, illness, or addictive disorders Engage in ongoing self-examination of feelings and behaviors Differentiate between sexual attraction and acting out Be aware of adverse consequences Establish behavioral limits in responding to erotic advances firmly and consistently Terminate/Refer/Consultation if necessary

Sexual Function-Related Psychopharmacology (Stahl, 2004): 

Sexual Function-Related Psychopharmacology (Stahl, 2004) Libido = mesolimbic dopamine pathway Arousal = acetylcholine>autonomic parasympathetic innervations nitric oxide>smooth muscle “NO laughing matter” N2O Orgasm = Serotonin exerts an inhibitory action on orgasm and norepinephrine an excitatory or facilitatory action

Neurobiology and Neuropharmacological Treatment of Sexual Disorders(Bradford, 2001;Can J Psychiatry): 

Neurobiology and Neuropharmacological Treatment of Sexual Disorders (Bradford, 2001;Can J Psychiatry) Level I - C/B and Relapse Prevention regardless of the severity of the paraphilia Level II - SSRI’s for mild paraphilia Level III – Add small dose of anti-androgen if SSRI not effective in 4-6 weeks Levels IV-VI - variations of oral/IM (MPA), and (LHRH) agonist

Inclusion: 

Inclusion Trauma Work – all parts of self False Messages Spirituality Blending of Stepwork and Values Mixed Gender Collages / Drawings of Addict REACH Vocational Acceptance

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Workplace Monitoring Physiological Monitoring Medication Compliance Therapeutic Monitoring Family Monitoring Community/Social Monitoring Static (Dispositional) vs. Dynamic (Contextual) Monitoring Titration Monitoring

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The capacity to experience a wide range of feelings deeply with liveliness, joy, vigor, excitement and spontaneity Capacity to expect appropriate entitlements of mastery and pleasure, as well as the environmental input necessary to achieve these objectives The capacity for self activation and assertion, and to identify one’s unique individuality, wishes, dreams and goals and to be assertive in expressing them autonomously Acknowledgement of self-esteem so that one can acknowledge that they have coped with a problem in a positive and creative way Ability to soothe painful feelings (Masterson)

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(Masterson) Ability to make and stick to commitments to relationships and career goals, despite obstacles and setbacks Creativity – the ability to replace old familiar patterns of living and problem solving with new and equally or more successful ones. This includes rearranging intrapsychic patterns that block self-expression Intimacy – the capacity to express self fully and honestly in close relationships with minimal anxiety regarding abandonment and engulfment Ability to be alone without feeling abandoned Continuity to self, or a sense of oneself consistent in diverse situations

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Requires a restatement of the Cartesian dictum from “I think therefore I am” to “He/She [the caregivers] thinks that I am, therefore I am.” REFLECTIVE FUNCTION (Fonagy & Target,2000)

ATTACHMENT STYLES: 

ATTACHMENT STYLES Romantic Relationships (choice) Relationship Adjustment Emotional Well-being Working Models of Self/Other Marital Quality Parenting Capacity

Slide80: 

Radical Acceptance Belonging

Vacuum of Choice (Yanki Tauber, 2005): 

Vacuum of Choice (Yanki Tauber, 2005) Since we can choose, we must choose some course of action or we will never grow and expand to fill the ‘vacuum’ of personal development implicit in the Jungian individuation process. Empowerment to choose congruently and appropriately might be seen as a fundamental goal of therapy.

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Professional Enhancement Program www.pinegrovetreatment.com/events.asp

MONITORING THE FUTURE: 

MONITORING THE FUTURE

Preventing Burnout: 

Preventing Burnout Personal Live your personal values Open, honest, direct communication Responsibility,Accountability, Inclusion,Respect Spending time with family and friends Engaging in religious/spiritual activity Self-care Adopting a healthy outlook Having a supportive spouse or partner

Preventing Burnout: 

Preventing Burnout Work Having control over the environment Finding meaning in your work Setting limits Having a mentor Having adequate administrative support systems