Nurse, Doctors, and Intimate Relationships with Patients

Most health care related professional licensing schemes contain a uniform proscription against engaging in sexual intimacies with clients.  This sexual conduct bar does not depend on consensual or non-consensual acts.     Violating this conduct is the first and surest way to lose your professional license.  Prior relationships with current licensee and current relationships with former patients also creates huge problems.

The General Assembly, through the Pennsylvania Code defines  Sexual intimacies as romantic, sexually suggestive, sexually demeaning or erotic behavior. Examples of this behavior include the following:

• (i) Sexual intercourse, or any touching of the sexual or intimate parts of the person for the purpose of arousing or gratifying sexual desire in either person.
• (ii) Nontherapeutic verbal communication or inappropriate nonverbal communication of a sexual or romantic nature.
• (iii) Sexual invitations.
• (iv) Soliciting or accepting a date from a client/patient.
• (v) Masturbating in the presence of a client/patient or encouraging a client/patient to masturbate in the presence of the licensed marriage and family therapist.
• (vi) Indecent exposure, kissing, hugging, touching, physical contact or self-disclosure of a sexual or erotic nature.  49 Pa. Code § 48.1

Section 49 Pa. Code § 21.146a, is a catch-all Pennsylvania Code provision setting forth as a procedural matter, not even a substantive violation,  a rule stating:

• (a)  The consent of the patient to any sexual impropriety or violation is not a defense to any disciplinary charge for violation of the act or this subchapter.
• (b)  Evidence of specific instances, opinion evidence, or reputation evidence of a patient’s past sexual conduct is not admissible in proceedings brought under §  21.148(b)(9) (relating to standards of nursing conduct).  The Board may consider sexual relationships between the nurse and the patient occurring prior to the professional relationship.
• (c)  A nurse who attempts to raise as a defense an argument that conduct prohibited as a sexual violation or sexual impropriety was necessary or appropriate to the treatment of a patient shall be required to demonstrate competency in practice which relates directly to the treatment of sexual function or dysfunction. This competence may be demonstrated through educational training and supervised clinical experience. Appropriate discussions of sexual matters between a nurse and a patient shall be fully documented in patient records.

Apparently this conduct is prevalent in the psychology, psychiatry, licensed marriage and family therapist, and LSW and professional counselor professions.  I say this because the language in each of these licensing regulatory schemes is exact, precise, and consistently repeated throughout.   The law is very clear about this topic: 49 Pa.Code § 47.61 states: Sexual intimacies between a licensed social worker or licensed clinical social worker and a current client/patient, or an immediate family member of a current client/patient, are prohibited.  More importantly, licensed social workers and licensed clinical social workers may not accept as client/patients individuals with whom they have engaged in sexual intimacies.  For how long you ask?  Sexual intimacies between a licensed social worker or licensed clinical social worker and a former client/patient, or an immediate family member of a former client/patient are prohibited for 7 years following the termination of the professional relationship.

Violation of these provision will warrant disciplinary action:

• (a)  A violation of § §  47.61—47.63 (relating to prohibited conduct; former sexual partners as clients/patients; sexual intimacies with a former client/patient or an immediate family member of a former client/patient) will be deemed unprofessional conduct and will subject the licensed social worker or licensed clinical social worker to discipline under section 11(a)(2) of the act (63 P. S. §  1911(a)(2).
• (b)   The consent of a former client/patient or immediate family member of a former client/patient to engage in sexual intimacies with the licensed social worker or licensed clinical social worker is not a defense in any disciplinary action brought under § §  47.61—47.63.

Pennsylvania does not recognize, along with all other states, that a mental health professional’s conduct in engaging in a sexual affair with a patient is actionable in tort (a medical malpractice action).  Thierfelder v. Wolfert, 617 Pa. 295, 327, 52 A.3d 1251, 1271 (2012).  However, our Commonwealth court routinely concludes the State Board of Medicine properly orders, and it is within their authority, that psychiatrist’s license to practice medicine be revoked on ground that he had engaged in sexual relations with his patients.  (“Revocation of psychiatrist’s license was reasonable sanction in light of his conduct.) Starr v. State Bd. of Med., 720 A.2d 183 (Pa. Commw. Ct. 1998); Morris v. State Bd. of Psychology, 697 A.2d 1034 (Pa. Commw. Ct. 1997).

 

In these cases, the court concludes the Board of Medicine, and other boards, are entitled to deference in their determination of what constitutes “unprofessional conduct” as that term is used in Medical Practice Act (or their licensing schemes) section providing that practitioner may be disciplined for “unprofessional conduct.” 63 P.S. § 422.41(8).  As there is no per say rule of revocation, the regulatory language stated above in the counseling fields is overlapped by the Medical Practice Act.

There, sections 41(8) and (9) of the Medical Practices Act state that the Board shall have the authority to impose disciplinary or corrective measures on a board-regulated practitioner for

• (8) Being guilty of immoral or unprofessional conduct. Unprofessional conduct shall include departure from or failing to conform to an ethical or quality standard of the profession. In proceedings based on this paragraph, actual injury to a patient need not be established.
  • (i) The ethical standards of a profession are those ethical tenets which are embraced by the professional community in this Commonwealth.
  • (ii) A practitioner departs from, or fails to conform to, a quality standard of the profession when the practitioner provides a medical service at a level beneath the accepted standard of care. The board may promulgate regulations which define the accepted standard of care. In the event the board has not promulgated an applicable regulation, the accepted standard of care for a practitioner is that which would be normally exercised by the average professional of the same kind in this Commonwealth under the circumstances, including locality and whether the practitioner is or purports to be a specialist in the area.
• (9) Acting in such manner as to present an immediate and clear danger to public health or safety.  63 P.S. § 422.41 (8) and (9).

The Boards and the courts consistently determine that having sexual intimacies with clients breaches ethical standards, standards of care, and constitutes immoral or unprofessional conduct.   “Unprofessional conduct” includes “those breaches of trust, confidence and reliance, necessarily attendant upon the intimate relationship of physician and patient, which amount to gross abuses of the standards of professional conduct generally recognized as essential to the proper practice of medicine and surgery.”  As well, the specific regulations above clearly state that it is of no consequence that intimacies occur either before or after a terminated client relationship.  Importantly,

the professional who, during course of therapeutic relationship, engages in sexual intimacies with client may not absolve himself or herself from professional liability by ceasing to provide therapy while sexual relationship continues, or billing for services and masquerading the sex as a therapy. 49 Pa. Code § 41.61. Giddings v. State Bd. of Psychology, 669 A.2d 431 (Pa. Commw. Ct. 1995).

Call me to discuss your legal issues.

 

 

What is and is not Psychology?

In preparation for recent hearing, I came across an extremely complex legal topic. The issue is to what extent of can licensees under the Pennsylvania State Board of Social Workers, Marriage and Family Therapists and Professional Counselors  practice their profession short of practicing psychology.

What are these practices?

• “PRACTICE OF MARRIAGE AND FAMILY THERAPY.” The professional application of psychotherapeutic and family systems theories and techniques to the evaluation, assessment and treatment of mental and emotional disorders, whether cognitive, affective or behavioral. The term includes the evaluation and assessment of mental and emotional disorders in the context of significant interpersonal relationships and the delivery of psychotherapeutic services to individuals, couples, families and groups for the purpose of treating such disorders.

• “PRACTICE OF PROFESSIONAL COUNSELING.” Includes, to the extent compatible with a practitioner’s education and professional competence, all of the following:
  • (1)  The application of principles and practices of counseling, mental health and human development to evaluate and facilitate human growth and adjustment throughout the life span and to prevent and treat mental, emotional or behavioral disorders and associated stresses which interfere with mental health and normal human growth and development.
  • (2)  The evaluation and assessment of normal and abnormal mental, emotional, social, educational, vocational, family and behavioral functioning throughout the life span; individual, group, family counseling and psychotherapy; crisis intervention, career counseling and educational and vocational counseling; functional assessment of persons with disabilities; and professional consulting.
  • (3)  Professional counselors’ utilization of verbal and nonverbal approaches and specialization in the use of arts-based therapeutic approaches, such as art, dance, music or drama, to accomplish treatment objectives.

• “PRACTICE OF SOCIAL WORK.” Offering to render or rendering a service in which a special knowledge of social resources, human personality and capabilities and therapeutic techniques is directed at helping people to achieve adequate and productive personal, interpersonal and social adjustments in their individual lives, in their families and in their community or holding oneself out to the public by any title or description of services incorporating the term “social worker” or using any words or symbols indicating or tending to indicate that one is a social worker, except as otherwise provided by this act.

Conversely, the Professional Psychologists Practice Act, 63 Pa. Cons. Stat. § 1203(3) also provides significant guidance.  The Psychologist Act creates a separate exemption for qualified members of other recognized professions including, but not limited to Social Workers, Marriage and Family Therapists and Professional Counselors. This section  1203(3) of the Psychologists Act states:

Nothing in this act shall be construed to prevent qualified members of other recognized professions, including, but not limited to, clergy, drug and alcohol abuse counselors, mental health counselors, social workers, crisis intervention counselors, marriage and family therapists, pastoral counselors, rehabilitation counselors and psychoanalysts, from doing work of a psychological nature consistent with the training and the code of ethics of their respective professions or to prevent volunteers from providing services in crisis or emergency situations. This exemption applies only to the practice of the respective listed profession.

So, what is practicing Psychology?  “Practice of psychology” means offering to render or rendering to individuals, corporations, institutions, governmental agencies, or the public for remuneration any service involving the following:

(i) The application of established principles of learning, motivation, perception, thinking, and emotional relationships to problems of personality evaluation, group relations, and behavior adjustment. The application of said principles includes, but is not restricted to, counseling and the use of psychological methods with persons or groups with adjustment problems in the areas of work, family, school, and person?-1 relationships; . measuring and testing· of personality, intelligence, aptitudes, and emotions, and offering services as a psychological consultant.

(ii)(a) “Measuring and testing,” consisting of the psychological assessment and evaluation of abilities, attitudes, aptitudes, achievements, adjustments, motives, personality dynamics and/or other psychological attributes of individuals, or groups of individuals by means of standardized measurements or other methods, techniques or procedures recognized by the science and profession of psychology, (b) “psychological methods,” consisting of the application of principles of learning and motivation in an interpersonal situation with the objectives of modification of perception and adjustment, and requiring highly developed skills in the disciplines, techniques, and methods of altering through learning processes, attitudes, feelings, values, self-concept, personal goals· and adaptive patterns, ( c) “psychological consulting,” consisting of interpreting or reporting upon scientific fact or theory in psychology, rendering expert psychological opinion, psychological evaluation, or engaging in applied psychological research.

This definition contains numerous elements, which can be broken down as follows: (1) the practitioner offers to render or renders (2) to individuals, corporations, institutions, governmental agencies, or the public (3) for remuneration ( 4) any service involving one or more of the following:

(a) the application of established principles of learning, motivation, perception, thinking, and emotional relationships to problems of personality evaluation, group relations,, and behavior adjustment, which established principles include measuring and testing of personality, intelligence, aptitudes, and ’emotions, and offering services as a psychological consultant; or (b) psychological assessment and evaluation of abilities, attitudes, aptitudes, achievements, adjustments, motives, personality dynamics and/or other psychological attributes of individuals by means of standardized measurements or other methods, techniques or procedures recognized by the science and profession of psychology; or (c) “psychological consulting,” consisting of interpreting or reporting upon scientific fact or theory in psychology, rendering expert psychological opinion, psychological evaluation, or engaging in applied psychological research.

In applying these definitions to the exemptions, 49 Pa. Code § 41.7 incorporates a statement of policy that provides guidelines for determining whether a given group qualifies as a “recognized profession” for the purposes of section 63 P .S. § 1203(3). Those guidelines read as follows:

(1) The group’s activity and focus must be based on an identifiable body of theoretical knowledge which, although it may include areas of coII1I11on knowledge shared with psychology, is demonstrably different, in the aggregate, from the body of theoretical knowledge underlying psychology.
(2) The group must regulate entrance into professional membership by means of standards of knowledge, training and proficiency generally accepted by the profession with which it identifies.
(3) ) . The group’s activity must be guided by generally accepted quality standards, ethical principles and requirements for an independent profession.
(4) The group must exhibit the ordinary accoutrements of a profession, which may include, but are not limited· to, professional journals, regional and national conferences, specific academic curricula and degrees, continuing education opportunities, regional and national certification and awards for outstanding practice within the profession.

More importantly, Section 1203(3) does not absolving these other licensed professionals from the prohibition against holding themselves out to the public by any title incorporating the words “psychological,” “psychologist” or “psychology” without first obtaining a license to practice psychology pursuant to the act.  The blanket advertising limitation set forth in section 1203 states:

It shall be unlawful for any person to engage in the practice of psychology or to offer or attempt to do so or to hold himself out to the public by any title or description of services incorporating the words “psychological,” psychologist” or “psychology” unless he shall first have obtained a license pursuant to this act, except as hereinafter provided:

Pursuant to the Ethical Principal 4(b) of the board’s regulations, “only psychologists licensed by a state board of psychologists examiners may be listed under the heading of psychologists in the yellow pages of the telephone directory.” 49 Pa. Code § 41.61.

Dezen v. Bureau of Prof’l & Occupational Affairs, 722 A.2d 1135 (Pa. Commw. Ct. 1999) discussed this issue. Dezen, a licensed social worker advertised in the Yellow Pages his ability to provide psychological counseling and similar services. The board found that he was not licensed as a psychologist and could not advertise his testing services as such.  The case law clearly precludes any other licensed professionals from holding themselves out to the public by any title or description of services incorporating the term using any words or symbols indicating portending to indicate that he or she his license or authorized to practice in any other capacity send their specific licensed professional.

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