Seeking input about an issue that came up in practice

[sunlioness]

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Hey everyone-

I just found out that one of the therapists who has been referring me patients for meds isn't licensed. Her degree is actually in ENGLISH, of all things. I had asked her earlier why she didn't bill insurance and her answer at that point was, "it's just too much of a hassle." I actually accepted that as a reasonable answer, so now I am feeling that I was lied to in addition to everything else. I am seeing 3 of her clients for meds and my impression of her based on her clients is she's not that great of a therapist. That's fine . . . I don't think she's awful or boundary-impaired or anything malpractice-worthy. Just not that effective. And certainly there are people with whom I work who are licensed whom I'm not all that impressed by either.

This has been pretty eye-opening for me. I didn't even realize people were out there advertising themselves and doing therapy without a license aside from "life coaching." I didn't realize it was even legal. Is it? I have a call in to my insurance company's risk management number, so I am going to run the whole scenario by them to see what I should do about it, but I was wondering if anyone else had experience with this sort of thing or any general opinions/experiences/advice.

Thanks!

SL

 

[Doctor Bagel]

Wow, that seems really odd to me, too. I also was under the impression that you needed to be licensed to be a "therapist." I'm wondering if her patients know. What type of therapy training did she have? Let us know what you find out.

 

[OldPsychDoc]

Well, as they used to say about Stuart Smalley, maybe she is "a caring nurturer, a member of several 12-step programs, but not a licensed therapist".
(She should run for Senate, maybe?)

 

[masterofmonkeys]

'therapist' is not a protected term from what I understand. So I don't think you can do anything.

 

[erg923]

Actualy she is only doing anything illegal if she refers to herself as a something shes not (ie., MFT, social worker, psychologist) or has faked any credentials, licenses, or diplomas. The generic term of "therpaist" is not protected under the law to my knowledge. However, she is operating at her own peril, as this is tort lawsuit ready to happen. Especially if she doesnt disclose this to her patients, they could have a field day with her in civil court. Moreover, she probably doesnt have any malpractice insurance, because you need to have a license (or be enrolled in a training program) in order to get it.

I stongly, strongly suggest that you politely outline the the slipperly slope she is operating on, and articulate how this can be dangerous to both patients and her own livelyhood. Moreover you need to point out that a persons medical record is a permanent legal document and that diagnosing without proper training and knowledge is unethical, immoral, and dangerous to the well-being or her "clients." There is no telling how much bad "advice," misdiagnosis, dependecey, or iratogenic illness she is creating here.

 

[kugel]

Hmmmmm.....

State laws vary about licensing and just how you can present yourself, e.g. counselor vs therapist. Even if Risk Mgt says there's no serious problem, I might be tempted to let her know you're unclear on exactly how she is licensed, so you'd like her to provide that info - since your own insur company has requested that you identify the name and licensure type of every professional with whom you regularly share client info. If she indicates that she is not properly licensed according to your state laws, I would probably tell her that your insur company risk mgt lawyer has advised that you no longer regularly share "professional" information with her anymore, but that you can still provide certain specific vital information if the patient provides a signed consent for such release (just like you could to a family member or close friend to whom THE PATIENT wanted info released). And, or course, you would break confidentiality if it was required because of a realistic danger of serious injury or death.

Very sorry, but I can't risk having my insurance drop me.

When you have to do something others won't like -
BLAME IT ON THE LAWYERS!

 

[sunlioness]

Thanks for all the input. I'm actually concerned most about my OWN liability working in collaboration with an unlicensed therapist. The whole situation is just weird.

She is actually part of this group of therapists locally and she initially contacted me because she wanted to invite me to do peer supervision with them once every few months or so. I told her explicitly at the outset that I was not going to do anything that involved any liability for me. She assured me it wouldn't. I then asked her, quite reasonably, why they were willing to pay me for this if they legally didn't need it and I wasn't assuming liability. Her response: "We've just found it so helpful in the past to have a psychiatrists input that it's worth it to us." She presented this as something the entire practice did and enjoyed. They did not have me sign any sort of paperwork at all.

So I show up for it and there are only two people there. This woman and someone else. This woman lets slip that she isn't licensed, never went to school to become any sort of therapist and that in point of fact her degree is in English and she just sort of "fell into" the profession when working for a rehab facility. "But I have a lot of training in gestalt!" She stated proudly. She's been practicing this way already for 30 odd years. She also told me that the other woman coming wasn't licensed either though she had a PhD from a clinical psych program. She just had never bothered to sit for the licensing exam or complete her required hours. She even said, "That's why we need you to come."

So I was deliberately misled and I don't feel particularly inclined to do their group supervisions anymore. But I already am seeing 3 of this woman's clients. And I was wondering what that does for MY liability to be in collaboration with a therapist who is not licensed, never graduated from any sort of degree granting training program and who likely doesn't even carry her own malpractice insurance.

I'm pretty angry. Both at myself for allowing myself to be misled and at this woman for not being forthright with me.

We'll see what the lawyers have to say about the whole thing.

 

[ronin12]

it seems you did not have any formal contract with this therapist, if you are seeing her clients, it is in separate independent settings, rather any formal collaborative relationship. i doubt you will have any negative impact on your liability,especially you were deliberately misguided by this therapist. your insurance company will be in good position to guide you further.

I think it would be a good idea to contact state licensing board for therapists and inform them about this situation. depending upon state laws they will pursue it further. By not informing them especially after knowing they are not qualified or licensed, could cause potential liability issues.

 

[erg923]

She also told me that the other woman coming wasn't licensed either though she had a PhD from a clinical psych program. She just had never bothered to sit for the licensing exam or complete her required hours. She even said, "That's why we need you to come."

WOW. That is scary and this somemthing that needs to be reported to the APA state licensing board. A doctroal level psychlogist practicing indepedently without supersion with no license? Violates laws and the ethics code.

 

[whopper]

It struck me as how some people could do psychotherapy, yet have what I understand no to little training.

In NJ, some places, some social workers were even recommending medications. No they didn't prescribe them, but they sat through enough drug dinners and lunches to think they had a clue, and unfortuantely they sometimes had a better clue if a psychiatrist was not available. In these circumstances, the prescribing doctor was a PCP with little knowledge in psychotropics. As inappropriate as it was for the social workers to do what they did, they were only trying to make due with the situation they were in--no psychiatrist, the person was in need of supportive psychotherapy, there were few people if any for referrals.

IMHO real psychotherapy requires years of training, and more so than provided in most residencies. Passable psychotherapy? Someone who's read at least a few books in psychotherapy (and read them seriously), and had at least 100 hrs of training. No I don't think they necessarily have to be a Ph.D. psychologist of psychiatrist. At the very least a masters in a field such as counseling or psychology should be required.

 

[erg923]

IMHO real psychotherapy requires years of training, and more so than provided in most residencies. Passable psychotherapy? Someone who's read at least a few books in psychotherapy (and read them seriously), and had at least 100 hrs of training. No I don't think they necessarily have to be a Ph.D. psychologist of psychiatrist. At the very least a masters in a field such as counseling or psychology should be required.

This is where psychology (and psychiatry before it) has really failed IMHO. That is, you'd think it might be wise to pour research dollars into empirical data that demonstrated the superior client outcomes of psychologists (and psychiatrists) compared to other professions. This was not done until the 80s, so when managed care came on the scene, psychology and psychiatry had little to offer to back their assertions that their superior, longer training represented a better economic deal than cheaper clinicians. The research that has been done on the notion that psyhotherapy is indeed a skill gained by years of extensive training is not particularly overwhelming. For a good review, see Dawes (1996). Psychology and Psychotherapy Built on Myth.

The previous was the empirical evidence, but much can be said for an individuals experiences and encounters. Although the empirical evidence fails to find much, if any, differences in psychotherapy outcome between a doctortal level psychologist, a masters level clinician, and John Q Public.....I still find this very hard to believe. My experiences lead me to believe that doctoral level education doesnt necessarily make a better therapist, but does increase one's knowlege of what not to do in a therapuetic relationship. I have simply observed too many masters level folks who, although they are great therapists, are very prone to pitfalls that can sometimes cause more problems (being too much of advocate, encouraging the sick role, etc).

 

[Regnvejr]

Providing supervision for them is a whole different story. Are they going to then try to bill under your NPI number?

Seeing patients she also see is probably ok, but to engage in any form of formal arrangement with them put you at liability when they mess up.

And since they likely have no liability insurance, make one guess about who the lawyers will come after. 😱

 

[ronin12]

This is where psychology (and psychiatry before it) has really failed IMHO. That is, you'd think it might be wise to pour research dollars into empirical data that demonstrated the superior client outcomes of psychologists (and psychiatrists) compared to other professions. This was not done until the 80s, so when managed care came on the scene, psychology and psychiatry had little to offer to back their assertions that their superior, longer training represented a better economic deal than cheaper clinicians. The research that has been done on the notion that psyhotherapy is indeed a skill gained by years of extensive training is not particularly overwhelming. For a good review, see Dawes (1996). Psychology and Psychotherapy Built on Myth.

The previous was the empirical evidence, but much can be said for an individuals experiences and encounters. Although the empirical evidence fails to find much, if any, differences in psychotherapy outcome between a doctortal level psychologist, a masters level clinician, and John Q Public.....I still find this very hard to believe. My experiences lead me to believe that doctoral level education doesnt necessarily make a better therapist, but does increase one's knowlege of what not to do in a therapuetic relationship. I have simply observed too many masters level folks who, although they are great therapists, are very prone to pitfalls that can sometimes cause more problems (being too much of advocate, encouraging the sick role, etc).

it is quite difficult to measure the quality of psychotherapy by standardized tests. therapy outcome can be measured of different level of therapists. in my personal experience, skills of SW's as therapists are significantly lower then phd or psych D psychologists , as their education was never intended them to be therapists. iquest for cheap alternatives is driving this frenzy and it has adverse consequences for all the professions involved.

 

[erg923]

it is quite difficult to measure the quality of psychotherapy by standardized tests. therapy outcome can be measured of different level of therapists. in my personal experience, skills of SW's as therapists are significantly lower then phd or psych D psychologists , as their education was never intended them to be therapists. iquest for cheap alternatives is driving this frenzy and it has adverse consequences for all the professions involved.

Although, I kinda agree , there is simply no emprical evidence showing this. Antecdotal evidence and personal experiences can guide our personal opnions on the subject, but you can't present your opinion to an insurance company. They have to see the the evidence, and it is solely our fault (psychologists and psychiatrists) for not being able to find the effects (that we think exist) in the numbers. We should have been attempting this since the 40s. I can hardey blame midlevels for pushing to the front of the service line when we cannot demonstrate , unquivically, the superiority of our services as therapists over theirs. I think this should give us pause as to whether an effect truley exists at all (ie., Dawes, 1996).

 

[Anasazi23]

I think you could garner a lot from asking the meds patient about the 'therapy' sessions. How did she advertise herself? How does she refer to her therapist?

In truth, almost anybody can be a 'life coach' or 'therapist' without any formal training whatsoever. Many nurses do this actually. They have a B.A. in psychology, an R.N. degree (maybe) and started doing therapy years ago. If I could guess, these therapists are from the 1970's and have been doing this type of thing for years.

From a monetary standpoint, I don't see any implicit danger in "supervising" them either - so long as you have an understanding that it's really nothing more than a "talk" as more of a guest speaker, and not a clinical supervisory role per se.

If they do bill themselves, both literally and figuratively, as therapists or life coaches, it's not so much different than taking a referral from a patient's friend who feels she needs help....or is it?

 

[sunlioness]

I'm definitely not as freaked out about it as I was earlier. I am still going to talk to the lawyers and see what they say, but I am hoping that it's not a huge deal. They haven't asked me to bill for them and I certainly would not be willing to do that. I was told by someone yesterday (not a lawyer though) that if I got in writing that the "supervision" sessions are for "educational purposes only" and that I assume no clinical responsibility that would probably be enough. As to seeing their patients . . . what you guys are saying makes sense to me. But I used to work at a large group practice. That practice wouldn't allow their patients to see therapists that didn't actually work at the practice. I asked the medical director why that was the case and she said it was for reasons of liability. That as psychiatrists, we assume the liability of any therapist we work with and that it minimized the risk to only work with people on-site whom you trusted and could keep a good eye on. That didn't make a lot of sense to me and actually seemed offensive to the psychologists/LCSWs/LPCs/etc of the world (whatever you think of the value of their various trainings --they are licensed to practice independently) who should be able to legally stand on their own two feet, but I know that laws oftentimes don't make too much common sense. So I was worried that if I assume liability for the licensed therapists I share patients with, it might be especially bad liability-wise to share patients with someone who ISN'T and who therefore doesn't carry her own insurance policy. Like someone said above, I become the one with the pockets. Anyway, tomorrow's Monday so hopefully I'll get some answers and report back with the scoop. 🙂

 

[sunlioness]

Though on further reflection, the medical director at my former group practice got a 45% cut of everything the therapists working there brought in. She also wasn't the most honest person in the world when it came to business matters, so it's entirely possible she wasn't telling me the truth on that one either.

 

[ronin12]

Actually the previous medical director was not entirely wrong. it was a surprise for me when i learned during administrative psychiatry exam, that being psychiatrists we are laible for the therapists as well. we work collaboratively and sharing information and clinical status was of great importance , psychiatrists are considered to be the overall team leaders, inpatient or outpatient. In simple terms, if therapist makes mistake he/she plus psychiatrist are liable, if they work in same settings. if psychiatrists screws something, he/she is solely responsible.
"Bucks stop at psychiatrist".

 

[Therapist4Chnge]

In truth, almost anybody can be a 'life coach' or 'therapist' without any formal training whatsoever. Many nurses do this actually. They have a B.A. in psychology, an R.N. degree (maybe) and started doing therapy years ago. If I could guess, these therapists are from the 1970's and have been doing this type of thing for years.

Scary, but true. Because "therapist" is not protected and people have found holes in the laws, there are a great many people who work on the fringe. I would distance myself from them because if nothing else it could look bad that you worked with unlicensed people who may or may not be misrepresenting themselves to patients. Whether or not you are "legally" on the hook is not the only concern, as perception by peers can be equally as damaging.

RE: ronin12's comments. I haven't heard that about independantly licensed professionals such as a psychologist. If they were part of a treatment team a person could always sue or file a grievance against the team, though if an independantly licensed person is sued, their license is liable, not the licenses of the other team members. The term "Therapist" may be the differentiating point, as some MA/MS and paraprofessionals must be "supervised" and thus the supervisor would also be liable.

 

[ronin12]

it was worded as therapist in textbook, so it is a broad term. it seems logical to assume in team setting whole team is liable including psychiatrist,for independent psychologists,i doubt if they are independent , but if they are part of team outpt or inpt including psychiatrist then again psychiatrist will be liable as well.Because they are considered overall team leaders, due to Biopsychosocial modeal of training they receive.

 

[erg923]

This is not accurate at all. A psychologist has his/her own license and his/her own malpractice insurance. Unless the psychologist is a predoc or post-doc fellow who is recieving formal supervision, no one is liable (legally) for the actions of the psychologist except the psychologist themself.

 

[sunlioness]

That's the way it SHOULD be and the way it would make logical sense to be (and if it isn't that way, it's totally offensive to licensed independent therapists), but that doesn't mean it actually is that way. It asked me on my application for malpractice insurance if I worked with independent therapists. I can only assume they asked that because it was relevant to assessing my risk.

Anyway, as to the original situation . . . My insurance guys "strongly advised" me NOT to continue with the group. They said even if I had it in writing from them that the purposes were educational only as long as a case was even hinted at, that meant I could be held liable. Their being unlicensed made that even more high risk. So then I asked him what to do about the 3 patients this woman had referred to me. And he was stumped and had to get back to me. When he called back he asked if there was a person in charge of this group and I said there was. He advised that I call this person and ask him how these two "therapists" are practicing without being licensed. He said the laws are complex and there are some ways it could be legit, but he needed to know how the director of the group justified this in order to know. So I called the the group director (who is himself a licensed psychologist) and outlined the situation. I said that what I was initially presented as the case with the group thing (providers just really appreciating having a psychiatrist around to talk about things with), turned out NOT to be the case (ie the "english major" telling me after mentioning that she and the other women were unlicensed "that's why we need you!", that it came to my attention that these women weren't licensed and that I was very disappointed they had not been open with me at the outset especially as I had specifically asked at the beginning if this involved my assuming liability in any way and was assured that it did not. I asked them about this more than once actually even making the point, "You guys don't need to pay someone to informally get together and talk about cases. Why are you doing this?" to which the answer was "It's just so valuable to us to have a psychiatrist's input." I also said that I had called my risk management people and they wanted to know how these women were practicing without being licensed because there were some ways that this was legal. I haven't heard back yet. I also called the psychiatrist who worked with them before and left a message on HER voicemail just asking for her impression of the group, what it was like working with them and why she left. That last piece, I should have done at the outset.

 

[fMRI]

What are the issues the 'patients' go an see the 'therapists' for? If it is serious psychological/psychiatric stuff, I would consider acting in the patients' best interests and bring this issue up straightforwardly.

If it is relatively minor (like frustrated housewives having too much money they can't spend on astrologers and other stuff), I'd simply cease working with this group. But this 'soft option' is only an option if they really do no harm to people at risk.

You are already unsure how they introduce themselves, I'd advise the same hesitation around the issue how they represent your involvement with them.

Or let me put it in another way: you brought this up, have the courage to trust your guts. 😀

 

[fMRI]

I had asked her earlier why she didn't bill insurance and her answer at that point was, "it's just too much of a hassle." I actually accepted that as a reasonable answer, so now I am feeling that I was lied to in addition to everything else.

She lied to you -- why should she be any more professional when dealing with patients?

Past behavior is a good predictor for future behavior...

 

[Therapist4Chnge]

it was worded as therapist in textbook, so it is a broad term. it seems logical to assume in team setting whole team is liable including psychiatrist,for independent psychologists,i doubt if they are independent , but if they are part of team outpt or inpt including psychiatrist then again psychiatrist will be liable as well.Because they are considered overall team leaders, due to Biopsychosocial modeal of training they receive.

I think you should inquire further, as the part about psychologists not being independant is not true according to any of the state licensing requirements I've read, which is admittedly not all...but a good portion of states. Relying on a textbook is a recipe for disaster.

As for the "assuming" part, that is where problem are created when people don't find out definitively from reliable sources like a licensing board, legal department, etc.

As for the "overall team leader"....that would vary by location.

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As for your situation sun....run FAR FAR away, as there is a big 'ol heaping of malpractice waiting for those people and whomever they work with, particularly if you know what they are doing and still work with them professionally.

 

[ronin12]

I think you should inquire further, as the part about psychologists not being independant is not true according to any of the state licensing requirements I've read, which is admittedly not all...but a good portion of states. Relying on a textbook is a recipe for disaster.

As for the "assuming" part, that is where problem are created when people don't find out definitively from reliable sources like a licensing board, legal department, etc.

As for the "overall team leader"....that would vary by location.

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As for your situation sun....run FAR FAR away, as there is a big 'ol heaping of malpractice waiting for those people and whomever they work with, particularly if you know what they are doing and still work with them professionally.

I had no intention of starting any "team leader tug of war". I guess text book of administrative psychiatry and forensic portions of Kaplan and saddock are reliable enough resources.
psychologists are independent providers, they are definitely liable for their own practice, but my point is even if a psychiatrist is not a "team leader" being working as "collaborative collegue" and doing "med management" Psychiatrist are not immune from liability ,because they are engaged in "collaborative treatment team".That is why it is important for psychiatrists to be aware of psychotherapeutic aspects of treatment as well.It does not matter who is a "team leader".
SW therapists are also independent providers,along with master level therapist. they dont's require any supervision from psychiatrists.

 

[Therapist4Chnge]

psychologists are independent providers, they are definitely liable for their own practice, but my point is even if a psychiatrist is not a "team leader" being working as "collaborative collegue" and doing "med management" Psychiatrist are not immune from liability ,because they are engaged in "collaborative treatment team".

Fair enough. In that example everyone on the team could be liable, as they worked in collaboration with the other team members. My point was that in an earlier post you said, "for independent psychologists,i doubt if they are independent...", which was incorrect.

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sunlioness: Any word yet from the other psychiatrist?

 

[ronin12]

Fair enough. In that example everyone on the team could be liable, as they worked in collaboration with the other team members. My point was that in an earlier post you said, "for independent psychologists,i doubt if they are independent...", which was incorrect.

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sunlioness: Any word yet from the other psychiatrist?

I phrased it wrong, what I meant if psychologists are practicing indepdently and psychiatrists are not involved in that patient's care, even if they are in same group setting then psychiatrists are "not" liable. the moement psychiatrist is involved in care for patients, regardless of therapists qualification, they can be held liable , it does not matter if they were supervisors, colleagues , "team leaders" or outside contractors.
the important point is if therapist makes mistake he/she and psychiatrist can be liable, but therapist can not be liable in case of individual psychiatrist's mistake.

 

[erg923]

I phrased it wrong, what I meant if psychologists are practicing indepdently and psychiatrists are not involved in that patient's care, even if they are in same group setting then psychiatrists are "not" liable. the moement psychiatrist is involved in care for patients, regardless of therapists qualification, they can be held liable , it does not matter if they were supervisors, colleagues , "team leaders" or outside contractors.
the important point is if therapist makes mistake he/she and psychiatrist can be liable, but therapist can not be liable in case of individual psychiatrist's mistake.

Please operationalize this, what does this mean? Are you talking about in court of law?, in tort litigation?, their medical license? On what legal grounds could that argument be made? How exactly would an attourney argue, much less proove this relationship of responsibility? Can you site any cases where a psychiatrists was succesfully sued (tort) or had his medical licensed suspended because of someone elses action who also happened to be involved in that patients care?

 

[ronin12]

Please operationalize this, what does this mean? Are you talking about in court of law?, in tort litigation?, their medical license? On what legal grounds could that argument be made? How exactly would an attourney argue, much less proove this relationship of responsibility? Can you site any cases where a psychiatrists was succesfully sued (tort) or had his medical licensed suspended because of someone elses action who also happened to be involved in that patients care?

primarily it is related to tort claims, not medical lisence or court of law.

the reason given , due to biopsychosocial nature of psychiatrists training they are assumed to be "experts" in theese deciplines and considered (have to write it again) "Team Leaders".the broarder the scope of practice, broader is your liability and it encompasses nursing aspects of psychiatry as well.
Unfortunately I can not qoute any case, which I am aware of. I am referring to textbooks about this issue.

 

[sunlioness]

sunlioness: Any word yet from the other psychiatrist?

No word from ANYONE yet. Not the other psychiatrist OR the director of the group in question (who is a licensed psychologist). I don't know why not in the former case, but in the latter I have this image of him saying "Oh crap!" and trying to cover his ass. He gets another day before I call my people again.

 

[Anasazi23]

Please operationalize this, what does this mean? Are you talking about in court of law?, in tort litigation?, their medical license? On what legal grounds could that argument be made? How exactly would an attourney argue, much less proove this relationship of responsibility? Can you site any cases where a psychiatrists was succesfully sued (tort) or had his medical licensed suspended because of someone elses action who also happened to be involved in that patients care?

I can say convincingly that even though psychologists are independent practitioners, the psychiatrist can be held responsible for negligence in a variety of aspects related to coordinated care. These situations come up in either consultation requests - where inadequate information was given by the psychologist to the psychiatrist, or in supervisory relationships.

In more common practice, when damage occurs to a patient (one of the necessary three "D's" in malpractice), everyone is brought in, and the lawyer waits to see who is thrown out in summary judgment, and who has the deepest pockets insurance-wise. This is how both hospitals and individual docs are sued in cases of damage to a single patient. Not to mention that forcing them to become co-defendants strengthens the complainants argument.

I don't have my landmark cases book nearby, but you can check this out as an introductory primer:

http://books.google.com/books?id=W_...ge&q=psychiatrist captain of the ship&f=false

 

[ronin12]

I can say convincingly that even though psychologists are independent practitioners, the psychiatrist can be held responsible for negligence in a variety of aspects related to coordinated care. These situations come up in either consultation requests - where inadequate information was given by the psychologist to the psychiatrist, or in supervisory relationships.

In more common practice, when damage occurs to a patient (one of the necessary three "D's" in malpractice), everyone is brought in, and the lawyer waits to see who is thrown out in summary judgment, and who has the deepest pockets insurance-wise. This is how both hospitals and individual docs are sued in cases of damage to a single patient. Not to mention that forcing them to become co-defendants strengthens the complainants argument.

I don't have my landmark cases book nearby, but you can check this out as an introductory primer:

http://books.google.com/books?id=W_oiQKROp9MC&pg=PA501&lpg=PA501&dq=psychiatrist+captain+of+the+ship&source=bl&ots=hg_lTRxZE-&sig=B05bFmuCy6fUmEjbuxyIYVMEGGc&hl=en&ei=_CqwSvKMFpuetwfPvbDvCA&sa=X&oi=book_result&ct=result&resnum=1#v=onepage&q=psychiatrist%20captain%20of%20the%20ship&f=false

Thanks for posting this link.gives good insight into vicarious liability issues.

 

[sunlioness]

So I talked to the guy who runs that group today who is a licensed psychologist. He reports that he had NO IDEA that this would be a problem. That many psychiatrists have worked with the group before and none of them indicated any sort of problem and that he is surprised and also now scared that it seems to be one. "I think the thing is that they must be tightening up on this sort of thing these days." He stated that the english major is an "excellent therapist" and that she has "more training than most psychologists", but grants that none of this excellent training was degree granting or accredited in any way. He says that she bills herself as offering "counseling services." He asked me to please get back to him about what I find out with regards to sharing patients with her as he would "very much like to know."

This whole thing is just so odd. I don't get why they don't get that it's a problem. And then I start to self-doubt and think, "Well, maybe it isn't really a problem and I'm just being a stick in the mud". Until I go talk to other people whose jaws tend to drop. So hence another reason for posting here, a nice good SDN reality check.

 

[erg923]

Did you ask him to explain his rationale/thought process on why he though it wasnt/shouldnt be a problem?

I can't understand someone who is trained as clinical scientist in a diciplne which prides its self on producing people who are critical thinkers, that doesn't have the slightiest idea that he is riding an ethical and legal slippery slope?

Makes me wanna do that "Really!......." sketch from snl weekend update with seth Myers and Amy Poehler

 

[erg923]

He stated that the english major is an "excellent therapist" and that she has "more training than most psychologists",

Did you ask him why he thinks this is at all relevant? Does he think is something a lawyer will just except without challnge. Naive much? How out of touch is this person?

 

[sunlioness]

Did you ask him to explain his rationale/thought process on why he though it wasnt/shouldnt be a problem?

Apparently it wasn't a problem because no one ever told him it was a problem before. Apparently he relies on psychiatrists to tell him these things.

I can't understand someone who is trained as clinical scientist in a diciplne which prides its self on producing people who are critical thinkers, that doesn't have the slightiest idea that he is riding an ethical and legal slippery slope?

Or as my licensed psychologist friend just emailed me: "But what the heck - doesn't he do his 6 ethics CEs every 2 years????"

Did you ask him why he thinks this is at all relevant? Does he think is something a lawyer will just except without challnge. Naive much? How out of touch is this person?

That I didn't ask him. I did say diplomatically (and untruthfully, actually) that I wasn't calling into question English major's skills as a therapist, but that I did need to look out for my own interests. He seemed to understand that.

 

[ronin12]

I would still suggest reporting this to state psychology/therapist licensing board.At least talk to them on phone and inquire about their regulations.

 

[Therapist4Chnge]

I would still suggest reporting this to state psychology/therapist licensing board.At least talk to them on phone and inquire about their regulations.

Absolutely.

 

[Faebinder]

Step 1) Find another job and leave.


Step 2) Call the state boards of psychology and also of psychiatry and report this.

Step 3) The boards will take care of this for you.

Reasons behind this... a) you are liable for poor therapy when you refer people to bad therapy. Doc, why did you refer me to this english major who is not trained in therapy when i needed dialectical behavioral therapy for my borderline personality... you wasted so much of my money and time. b) You are a professional with ethics.. this is unethical and substandard. You can't sleep with a good conscious.

Sorry for delivering bad news.🙁

 

[sunlioness]

I never referred to her. She referred to me before I knew she wasn't licensed. Never occurred to me to even think that such a thing would happen, so I wasn't actively checking the credentials of therapists referring to me. I don't work for these people, thankfully --they just wanted me to run a supervision group for them, which I have already extricated myself from. I'm self-employed so I don't need to find a new job; I just need to know what to do with the patients of this woman whom I have already seen and established a treatment relationship with. Waiting for the lawyers to call back on that one. I wouldn't know who to report this woman to given that being unlicensed, she isn't subject to anyone, which is part of the problem. She isn't claiming to be a psychologist or a LCSW or an LPC or anything, so I don't know how reporting her to those boards would help. Anyway, I'll let you guys know what the lawyers say. I'm actually grateful that I found out about this when I did. That was a blessing. It could have been so much worse later. 🙂

 

[michaelrack]

they just wanted me to run a supervision group for them, which I have already extricated myself from. I'm self-employed so I don't need to find a new job; I just need to know what to do with the patients of this woman whom I have already seen and established a treatment relationship with.

Here's what you should do:

sit down individually with the patients. Tell them that their "counselor" is not a licensed professional. Tell the patients that they are free to talk to/see who they like, but that you as a psychiatrist can have no involvement with the unlicensed "counselor", and will not be speaking to this "counselor" further. After that, pretend that this "counselor" does not exist and appropriately treat your patients. If you think they need psychotherapy, provide it yourself or refer them to another licensed professional. If they want to keep on seeing the unlicensed "counselor" while doing this, that's fine- you should think of it in your mind as them talking to a supportive friend. If they refuse to follow through with your recommendations to receive professional psychotherapy from a licensed professional, consider firing the patients.

 

[ronin12]

I never referred to her. She referred to me before I knew she wasn't licensed. Never occurred to me to even think that such a thing would happen, so I wasn't actively checking the credentials of therapists referring to me. I don't work for these people, thankfully --they just wanted me to run a supervision group for them, which I have already extricated myself from. I'm self-employed so I don't need to find a new job; I just need to know what to do with the patients of this woman whom I have already seen and established a treatment relationship with. Waiting for the lawyers to call back on that one. I wouldn't know who to report this woman to given that being unlicensed, she isn't subject to anyone, which is part of the problem. She isn't claiming to be a psychologist or a LCSW or an LPC or anything, so I don't know how reporting her to those boards would help. Anyway, I'll let you guys know what the lawyers say. I'm actually grateful that I found out about this when I did. That was a blessing. It could have been so much worse later. 🙂

though they are not claiming to be therapists but they still are practicing it. like some one practice medicine, without calling self doctor.I understand it is awkward situation for you, as it will be obvious to them you informed the licensing board, but at least inquire the board anonymously.
After informing your pts about them, make sure you mention it in your medical record.

 

[sunlioness]

Here's what you should do:

I think that's what it's going to come down to actually and that's what I am mentally prepared to do. All three of them happen to be scheduled next week. I know that one of the three will probably pick up and discharge himself at that point, which is totally fine. He told me during his initial eval that he left his previous psychiatrist because "she wouldn't talk to [english major]." I thought he meant that he preferred his treatment providers to work in closer collaboration than he was experiencing, but now I wonder if he may have literally meant that she wouldn't talk to her. Again, it didn't occur to me to ask because people telling me they want more communication among their treatment providers isn't all that unusual (and people have probably left me saying the same, for all I know, so it's not a condemnation of anyone else. I've actually in general heard good things about this other doc).

 

[OldPsychDoc]

Here's what you should do:

sit down individually with the patients. Tell them that their "counselor" is not a licensed professional. Tell the patients that they are free to talk to/see who they like, but that you as a psychiatrist can have no involvement with the unlicensed "counselor", and will not be speaking to this "counselor" further. After that, pretend that this "counselor" does not exist and appropriately treat your patients. If you think they need psychotherapy, provide it yourself or refer them to another licensed professional. If they want to keep on seeing the unlicensed "counselor" while doing this, that's fine- you should think of it in your mind as them talking to a supportive friend. If they refuse to follow through with your recommendations to receive professional psychotherapy from a licensed professional, consider firing the patients.

I would take a different tack, honestly. I'd approach it the same way as if a pt were getting counseling from a pastor, or seeing a chiropractor or naturopath.
--get a signed release to allow communication. If they've divulged to their pastoral counselor or coach or teacher or grandma that they're suicidal, YOU WANT communication with that person. It can totally make the difference whether you get them to a more intensive level of care, keep them compliant, etc.
--make clear in your record that you know that this outside individual is providing care. You can't stop the pt from allowing them influence, any more than you can get them out of an abusive relationship.
--make clear to the patient that they are receiving pastoral counseling, or supportive advice, or compassionate listening or whatever, but that it is not "licensed therapy". If you have a problem with how they're being directed--e.g. there is unhealthy or dangerous advice being given--document the hell out of it, let the pt know your concerns, and I suppose you can consider "firing" the patient if they don't comply with a reasonable standard of care suggestion from you, but I don't think that you can tell them that you're just not going to communicate with that important influencer in their life and expect to help them in any way.

 

[DebDynamite]

I am in my outpatient year of training right now. We primarily see psychotherapy patients, 90% of the time. It's in a University based clinic ("University Specialty Clinics"). Whenever we learn that a patient is seeing ANY other form or "counselor"/"therapist".... they instantly become med management only. That is the policy here as dictated by our clinic regulations.

I have no idea if attorneys are behind the policy or not. We do obtain a release form and try to communicate with the therapist. We actually transfer them to a med management clinic and explain to them that it is not therapeutic for a pt to have more than one therapist (boundary issues, etc), also that for the sake of resident learning, the resident needs to be the only provider of therapy. Usually, their insurance company won't accept a therapy bill from more than one provider anyway...

 

[michaelrack]

I would take a different tack, honestly. I'd approach it the same way as if a pt were getting counseling from a pastor, or seeing a chiropractor or naturopath.
--get a signed release to allow communication. If they've divulged to their pastoral counselor or coach or teacher or grandma that they're suicidal, YOU WANT communication with that person. It can totally make the difference whether you get them to a more intensive level of care, keep them compliant, etc.
.

Your approach is reasonable.
I would like to point out that pastoral counseling, while not the same as psychotherapy, is legitimate- there are plenty of psychiatric textbooks and articles that state that referral for pastoral counseling can be appropriate for spiritual concerns.

 

[sunlioness]

The risk management people at my insurance co ran it by some local lawyer types. The question being whether I should continue to collaborate on patient care with this unlicensed English major type person. I'm not doing the group anymore. What they said, essentially, was that it's up to me and my "comfort level." I am not required to report her to any sort of governing authority unless she is claiming to be licensed. To my knowledge, she is not. They said my continuing to work with her on patient care was dependent on my "comfort level." And that if I decided NOT to work with her, I had to tell those 3 patients so in a way that would not be seen as disparaging her, because that could create problems all on its own.

To be honest, it's not the answer I really wanted. It begs the question what is my comfort level? Do I think this woman is a good therapist? No. Do I think she is any worse than a lot of licensed people out there? No, not really. But I honestly don't think she's that great. I also truly do not appreciate essentially having been lied to. I asked her several times if the purpose of this group (I am definitely not doing the group) was for me to assume any of their liability or give them any sort of "stamp of approval" and was assured each time that it was not. This turned out not to be the case. I resent that greatly and the thought of any continued relationship with this person for any reason is not pleasant. And thus for that reason alone, probably not the best for patient care. So going strictly on "comfort level", I need to talk to this person and her three patients and tell them that I will not continue working with her. I can do it in a non-disparaging way. I can say I don't work with unlicensed providers because of my own liability risk. It would be true and I wouldn't have to mention that I think she sucks on top of it and that she lied to me and also tried to tell me how "connected" we were (oh yes, I don't think I mentioned that bit. When I met with that group this woman said to the other woman who was there, "Sunlioness and I just have this connection. Can't you feel it? It's like we're the same somehow. What is that? Can't you tell?" And no, I didn't "feel it").

So I guess the answer is that I'm not comfortable and need to address it with this woman and with her patients. Now just to determine how best to do that (whether I say I won't see the patients at all or whether I tell them that I will see them, but not treat English major as their therapist) and then do it. Sigh. I wish it was already over with. One of my friends says she still thinks I should run it by MY state board and see what they say. I don't know how that would give me a different answer given that they would be looking at the same laws my risk management people looked at. Anyway, advice/input is welcome as always. I have one of these patients scheduled on Monday.

 

[pingouin]

Just out of curiosity, what are your patients saying about her? Do they feel like she's helping them or do they have concerns about whatever "therapy" it is that she's providing? If they do, that's certainly a nice opening for you to talk with them about transferring to a licensed professional- whether you or a non-MD therapist- for that part of their treatment.

 

[sunlioness]

They think she's the greatest thing since sliced bread. All three of them left their previous psychiatrist because they felt she wasn't willing to work together with their "therapist." One of them has been seeing her for over 10 years. Actually I think 2 of them might have been seeing her for that long. It doesn't seem they've made too much progress in that time either.