Mandated Psychotherapy with the Impaired Physician

| February 25, 2008 | 0 Comments

by Julie P. Gentile, MD

Dr. Gentile is Board Certified, American Board of Psychiatry and Neurology, Director of the Dual Diagnosis Program (Mental Illness/Intellectual Disabilities), Director of Medical Student Mental Health Services, and Assistant Professor, Department of Psychiatry, at Wright State University, Dayton, Ohio.

Editor Note

All cases presented in the series “Psychotherapy Rounds” are composites constructed to illustrate teaching and learning points, and are not meant to represent actual persons in treatment.

Abstract

Physicians and other prescribers of medication are in a unique position with regard to substance misuse. Each physician must abide by the licensing guidelines of the state medical board in their geographical location of practice. When a physician has legal charges regarding substance use, he or she must report to the medical board and undergo monitoring for several years. The recommendations of the board may include mandatory psychotherapy. The following composite cases are illustrative of the implications of one physician treating another physician under the auspices of a mandate.

Key Words

physician, impairment, substance abuse, psychotherapy, professionals, medical board, resident physician, psychiatric care

Introduction

The misuse of alcohol and drugs among physicians is a common cause of malpractice, absenteeism and complaints to the medical councils. This problem demands more attention in the field of medicine because it entails risks not only to the physicians themselves but to the population.[1]

This article reviews two composite case studies of physicians in treatment that were mandated to participate in psychotherapy by the State of Ohio Medical Board after drug-related legal charges. The physicians were both monitored by the State Medical Board for five years, and both were mandated to complete a variety of tasks, including a minimum of six months of psychotherapy. The psychotherapists were required to submit reports to the Medical Board every three months with information regarding adherence, mental status examination, and any concerns relevant to the case.

The following literature review gives an overview of clinical and demographic profiles of samples of physicians in treatment for alcohol and drug dependence, and evaluates psychiatric comorbidity and consumption-related consequences. Both of these are relevant to the success of a course of psychotherapy, specifically in reference to the motivation of the patient-physician regarding the therapy and also to the goals that may be achieved during the course of treatment.

There is higher percentage use of alcohol, tranquilizers, and psychedelics among medical students than medical graduates. Dependence rates are five percent for medical students and three percent for physicians.[2] The majority of substance-abusing physicians belong to medicine specialty (21%) and the majority prescribe drugs to themselves (37%).[1] In India, Kumar, et al.[2] found that stress (situational, personal, and professional), treatment considered by the subjects as abusive when going through medical school, and family history of alcoholism were the major risk factors determining substance use.[2]

In the 1992 National Household Survey on Drug Abuse, Hughes, et al., surveyed 9,600 physicians, stratified by specialty and career stage, who were randomly selected from the American Medical Association master file. The response rate after three mailings was 59 percent.[3] Physicians reported that they were less likely to have used cigarettes and illicit substances, such as marijuana, cocaine, and heroin, in the past year than their age and gender counterparts. They were more likely to have used alcohol and two types of prescription medications (e.g., minor opiates and benzodiazepine tranquilizers). Prescription substances were used primarily for self-treatment, whereas illicit substances and alcohol were used primarily for recreation. Current daily use of illicit or controlled substances was rare.[3] The conclusions of the study were that although physicians were as likely to have experimented with illicit substances in their lifetime as their age and gender peers in society, they were far less likely to be current users of illicit substances. The high prevalence of alcohol use among physician respondents was thought to be more a characteristic of their socioeconomic class than of their profession. A unique concern for physicians, however, is their high rate of self-treatment with controlled medications—a practice that could increase their risk of drug abuse or dependence.[3]

Hughes, et al.,[3] estimated the prevalence of substance use of 11 medical specialties from a national sample of 1,754 US resident physicians. The results found that emergency medicine and psychiatry residents showed higher rates of substance use than residents in other specialties. Emergency medicine residents reported more current use of cocaine and marijuana, and psychiatry residents reported more current use of benzodiazepines and marijuana.[4] Family/general practice, internal medicine, and obstetrics/gynecology were not among the higher or lower use groups for most substances. Surgeons had lower rates of substance use except for alcohol. Pediatric and pathology residents were least likely to be substance users.

Risk of addiction may be increased dramatically by unintentional exposure in the workplace to potent substances that sensitize the brain.[1] It is well known that second-hand inhalation of crack vapors is very dangerous, but rarely has alarm been raised about exposing anesthesiologists to second-hand fentanyl. In earlier studies,[1] anesthesiology residents did not have high rates of substance use, but more recent research suggests otherwise. Fry9 sent questionnaires investigating substance abuse to 128 anesthetic departments in Australia and New Zealand, of which 100 (78%) replied. Forty-four cases of substance abuse were reported. Abusers were more likely to be male, aged between 25 and 35 years, and abusing opiates. More than one precipitating cause was identified in 51 percent of cases; the most frequently reported were mental health and family problems. The pattern of substances abused was similar to that reported in a previous Australian survey 10 years prior. In keeping with an international trend, there appears to be an increased use of anesthetic agents.[9]

Psychiatric Disorders among Impaired Physicians

The issue of co-occurring psychiatric pathology arises when considering treatment issues, including psychotherapy. Brooke, et al.,[5] found that the most frequent pathways into substance use were personality difficulties (76 subjects, 52.8%) and anxiety or depression (46 subjects, 31.9%). A history of depression (n=36) was associated with perceived stress at work (p=0.014) and at home (p=0.06). Past neurotic disturbances (n=20) were associated with personality difficulties (p=0.035), anxiety or depression (p=0.004), and with an earlier onset of problematic substance use (30.2±8.3 versus 36.5±9.8 years, p=0.014). It is well known that substance use commonly co-exists with depressive disorders, anxiety disorders, and other psychiatric illnesses. Substance abuse/mental illness (SAMI) programs are offered for these dual disorders in many facilities.[5]

Another study of comorbidity was completed by Alves;[6] wherein, 198 subjects were surveyed for previous treatment episodes and drug of choice. Most of the subjects were men (87.8%), married (60.1%), with a mean age of 39.4 years (SD=10.7). Sixty-six percent had already been in inpatient treatment for alcohol and drug misuse. Sixty-nine percent were specialists practicing mainly internal medicine, anesthesiology, and surgery. Psychiatric comorbidity was diagnosed in 27.7 percent for Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV) Axis I and in six percent for DSM-IV Axis II.6 With regard to drugs, the most frequent pattern was use of alcohol and drugs (36.8%), followed by exclusive use of alcohol (34.3%), and exclusive use of drugs (28.3%). Thirty percent tried to achieve treatment by themselves. The social and legal problems observed were unemployment in the previous year (1/3 of the sample), marital problems and divorce (52%), car accidents (42%), and legal problems (19%). Professional problems presented in 84.8 percent, and 8.5 percent had problems within the Medical Councils.[6]

Lutsky, et al., studied prevalence of substance use disorders among various specialties as well as family history of abuse and the physicians’ perceptions of substance abuse treatment programs. Questionnaires were sent to 1,624 physicians in medicine, surgery, and anesthesia; all had trained at the same academic institution. A response rate of 57.8 percent was achieved. Comparison of prevalence of impairment rates showed no differences between surgery (14.4%), medicine (19.9%), and anesthesia (16.8%).[7]

Substance abuse was clearly associated with a family history of abuse; 32.1 percent of the abusers had a family history of such abuse compared with 11.7 percent of the nonabusers. Increased stress at various career stages did not appear to increase substance abuse; problem areas during medical life times were similar for each specialty. Substances most frequently used were marijuana (54.7%), amphetamines (32.9%), and benzodiazepines (25.1%). Seventy-three used psychoactive drugs, which were non-prescribed.[7] Drug counseling programs were judged inadequate by most. Use of alcohol and drugs by faculty members was reported by a number of respondents.

When a physician is monitored by a state medical board for substance use, one of the requirements may include mandated psychotherapy. In both of the cases described in this article, the physicians presented for psychodynamic psychotherapy and were required to complete a minimum of six months of treatment, in addition to multiple other requirements of the State of Ohio Medical Board. In each case, there were issues to explore in the psychotherapy that could benefit the physician-patient; however, one of the prerequisites for a successful course in psychotherapy is motivation of the patient and willingness to participate in the treatment.

Case One—Dr. E

Dr. E was a 45-year-old, divorced, male physician in private practice. He was mandated to undergo a minimum of six months of psychotherapy as part of the monitoring protocol of the State of Ohio Medical Board after receiving a traffic ticket for driving under the influence (DUI) eight months previously. Prior to this incident, Dr. E had no legal history. He contacted a local private psychiatrist and requested psychotherapy “for six months, starting as soon as possible.”

During the initial phone contact, Dr. E requested a reduced fee “since this should be professional courtesy.” He quickly shared the information about the DUI and added that alcohol “is not a problem for me, but I happened to get unlucky one night a few months ago.” He denied past or present use of any other substances.

Information gathered during the intake sessions showed that Dr. E had been divorced many years prior, with no long-term relationship for the last four years; he described himself as a “workaholic” since the divorce, and initially denied this was the case prior to the divorce, but eventually identified his work hours as one of several possible precipitants of the failure of the relationship.

Dr. E had a psychiatric history significant for depression, which he described as “stress” and for which he had not received previous psychotherapy, but he was taking escitalopram (Lexapro) samples obtained informally from a colleague in the primary care clinic at the hospital. He had no history of psychiatric hospitalizations and no history of previous psychotherapy.

Dr. E had minimal contact with his parents; his mother, who had multiple medical problems and dementia with psychotic features, would “never be able to apologize for all the things she did to us,” and his father would call approximately twice yearly to request money and assistance from him.

Dr. E attended college away from home and obtained an undergraduate degree in art history because “someone told me I couldn’t do it.” He met and married a woman 14 years his elder during his senior year of college “because she had a house and helped me get my first job.” They divorced after less than a year of marriage, because his ex-wife became “increasingly controlling” and ultimately reminded him of “my mother during my growing up years.”

Practice Point: Defining Psychotherapy

Six features have been identified as being common to all psychotherapies: 1) an intense, emotionally charged, confiding relationship with a helping person; 2) a rationale, which includes an explanation of the cause of the patient’s distress and a method for relieving it; 3) provision of new information concerning the nature and sources of the patient’s problems and possible ways of dealing with them; 4) strengthening the patient’s expectations of help through the personal qualities and status of the therapist; 5) provision of success experiences that heighten hope and enhance a sense of mastery; and 6) facilitation of emotional arousal, which seems to be a prerequisite to attitudinal and behavioral changes.[8]

Case One—Dr. E, continued

In the case of Dr. E, it was evident that he had many unresolved issues involving his developmental years, which had affected and continued to affect his relationships.

When Dr. E was asked, “Who are the important people in your life?” he responded “my patients.” He also described two of his partners in the surgery practice as people he could depend upon to cover his duties but “not people with whom I would spend holidays.” He stated he had no friends and admitted that he “did not process” his divorce.

Patient-Physician Selection for Psychotherapy

The question of who might benefit from psychotherapy is often debated.[8] One group of potential patients are those for whom treatment is clearly indicated and comprises persons whose symptoms are severe enough to significantly impair their ability to function in their occupations or to manage every day responsibilities as marital partners, parents, or members of the community. The question for this group is: Is psychotherapy the most efficacious treatment? Are there alternative approaches that would work as well or better?[8] With the advancement of psychotropic medications, the treatment options have clearly expanded in recent years; however, more recently, several controlled studies indicate that psychotherapy, either alone or combined with psychotropic medications, when judiciously administered for specific disorders, is a potent and effective treatment modality.[8] Dr. E was taking a selective serotonin reuptake inhibitor “informally” from a primary care physician. He had not shared the details of his personal history with this physician, and given the depth of his relationship issues and losses, there was much work to be done in the psychotherapy setting, but this depended on Dr. E’s intentions for this treatment format. Dr. E’s relationship problems might have intersected with his substance abuse, and perhaps some confusion about how much emotional “libido” to invest in his patients, rather than pursuing other types of relationships. It was possible Dr. E had a fear of intimacy and also of losing control of the relationship, needing the contact, but being rejected. Investing feelings only in patients fixed this problem for him, he thought, because he called the shots. It is subtle, but in a way this was a kind of boundary violation in his own head that was hurting him, though probably was not harmful to the patients, at least in this case. The real risk was that this boundary violation could be a prelude to others.

Practice Point: Motivation Issues When Psychotherapy is Mandated

Dr. E was mandated to pursue a minimum of six months of psychotherapy. Although this situation did not necessarily imply a poor prognosis, there may have been a significant problem with motivation. When psychotherapy is mandated, the patient may not see the need for change. In addition, there may be resentment of demands made on both time and money. One of the first things Dr. E mentioned in the initial phone contact when scheduling the appointment with the psychiatrist was “professional courtesy” and the implication of a reduced or waived fee. This was handled by the psychiatrist by reviewing the normal fees for service and an offer to talk in more detail at the first appointment if Dr. E wanted to discuss further. There are important transference and counter-transference issues to consider regarding monetary compensation. The psychiatrist must feel he or she is providing a valuable service that deserves compensation, and reducing a fee may affect the psychotherapist’s view of the treatment. The physician-patient is more than likely a patient who can afford the fee charged by the psychiatrist. Reducing or eliminating the fee may cause the therapist to devalue his or her service; such a stance may also serve to devalue the therapy in the patient’s eyes and thereby may undercut the therapeutic process.[8] It also places the patient in a more controlling position with respect to the psychotherapist, and in the case of Dr. E, this is what he did by investing his libido in patients, so being vulnerable in a relationship was already manifesting itself.

Case Two—Dr. P

Dr. P was a 35-year-old, single, female physician who worked as an interventional radiologist. She had a history of alcohol use during teenage years and early 20s; she described this alcohol consumption as a binge pattern. She attributed this to adolescent peer pressure, and by the time she was a junior in college majoring in pre-medical studies, her alcohol consumption had decreased to an occasional drink with friends.
She returned home after medical school because her sister was terminally ill, and she felt an obligation to be close by to assist her parents during this time.

Growing up, her father was a passive, “laid back” man who worked as an educator. She describes her mother as demanding and opinionated.
She felt isolated and rejected during grade school and high school, and was diagnosed with attention deficit hyperactivity disorder (ADHD), combined type, which became symptomatic by all accounts around six years of age. Dr. P’s mother refused to have her daughter evaluated because she “did not believe in medications.” Dr. P’s mother would berate her after school when she had difficulty concentrating, and told her on numerous occasions that she was “not as smart as the other kids at school.”

When Dr. P was interviewing for positions upon the completion of residency, she was in an automobile accident and began taking prescription opiate medication for pain control. She eventually became addicted to these medications, and after losing her position in the medical practice, she approached the Medical Board, requested their input, and pursued a plan to get re-established in the medical community. She completed a 28-day residential substance abuse treatment program, followed by an aftercare program and weekly meetings. She contacted a private psychiatrist to schedule “six months of appointments because it’s required by the Medical Board.”

During her stay at the residential program, Dr. P’s sister passed away and she was able to attend the funeral, but unable to be a part of the planning or assist her parents in other ways. She endorsed mild depressed mood, initial and middle insomnia, and decreased concentration (possibly secondary to the untreated ADHD), all of which was complicated by chronic knee and shoulder pain (untreated with medication). Dr. P exercised daily and continued physical therapy in an effort to relieve the pain. When asked to describe her goals for psychotherapy, Dr. P stated “grieve the loss of my sister and figure out why I can’t seem to make a relationship last more than a few months.”

Practice Point: Initiating the Therapeutic Relationship

Patients often have unrealistic expectations when they enter psychotherapy. Since Dr. P made it clear that she had the intention of terminating the psychotherapy after the mandated six months, the goals of the therapy had to be realistic, be discussed early on, and be revisited frequently.
When dealing with the physician-patient, there may be unrealistic concerns or fears, i.e. will the psychiatrist share any of the information about the physician-patient with other physicians? The physician-patient’s perception of the psychiatrist is an important component of the initiation of the psychotherapy. The majority of patients neither ask for directions nor assume they know how to relate to the therapist. In striving to discern what the therapist is really like, they proceed to imagine what he or she is possibly like.[8] This step may be taken automatically and unconsciously. The physician-patient will be able to identify with the psychiatrist given the shared educational process each has accomplished. The psychiatrist has the added layer of the physician-patient being a powerful or influential person in the community. Often there is added stress to perform and achieve a successful outcome, and with the addition of a six-month time limit for this mandated psychotherapy, the psychiatrist may feel extra pressure. Given that the physician-patient has multiple issues that require exploration, an early discussion about the goals of this psychotherapy is vital.

In the case of Dr. P, clearly her relationship with her mother and other significant events during developmental years (i.e., co-occurring ADHD) had affected her life course and would benefit from psychotherapy but all of these issues cannot be properly addressed in six months.

Practice Point: Determinants of Behavior and How Psychotherapy Works

Ego strength. Ego strength is an important quality to assess in determining a person’s capacity for psychotherapy; it indicates some ability to tolerate frustration, a discipline for the persistence required, and the willingness to look at the more unpleasant aspects of oneself. When assessing the ego strength of the patient, a legal record and a history regarding the use of mind altering chemicals is essential.[8] If the patient uses drugs or alcohol, under what circumstances? Is there a history of habituation, either now or in the past? Does the patient turn to substances during times of stress?

Unresolved developmental issues. Unresolved developmental issues are occurrences during childhood wherein the patient felt unsupported or unprotected; these may hold more dramatic emotional content when parents or other primary caregivers are involved. In the initial sessions both patient-physicians shared some unresolved issues from developmental years.

Repetition of patterns. As people forge new relationships, sometimes they recreate, often unintentionally, the same kind of relationship patterns characterized by their past. According to adult attachment theory, previous relationship patterns can re-emerge because the working models (i.e., mental representations) people hold of past relationships are highly accessible and are used to guide interpersonal behavior in novel circumstances.[10] In fact, this process is thought to partially explain the continuity of attachment patterns across time and context. With progress in further sessions in both of the presented case examples, both patient-physicians identified the repetition of particular behaviors and patterns, and how these patterns were affecting their relationships.

Insight and how it helps. Insight is the ability to see clearly and intuitively into the nature of a complex person, situation, or subject. Insight allows a person to understand and find solutions to their problems. For example, during session 16, Dr. P made the comment, “This really works, doesn’t it?” when referring to the psychotherapy. Dr. P had worked during and between sessions to make progress, and felt she had some tangible results in her daily life. Ultimately, she completed the mandated six months of psychotherapy and continued on to voluntarily complete a total of 24 months of treatment before a planned termination.

CONCLUSIONS

In our review of the literature on physicians with substance use issues, it is clear that there are defined risk factors, including psychosocial history, family history, and ego strength issues. It is also clear that certain medical specialties, including psychiatry, are more likely to have substance use issues than others. Another potential risk factor affecting substance abuse described in the literature pertains to occupational exposure for physicians working in the field of anesthesiology. Gold[1] discusses risk of addiction through exposure to drugs of abuse as an important, but relatively neglected, public health problem. Stress and access may play a lesser role in addiction among certain populations than originally thought. Risk of addiction may be increased dramatically by unintentional exposure in the workplace to potent substances that sensitize the brain.[1]

Physicians and other licensed professionals monitored from 2000 to 2006 by the State of Ohio Medical Board are summarized in Table 1. By reviewing Tables 2 and 3, we can see that the most common basis for disciplinary action by far is impairment by alcohol/chemical dependency/ illness. Other infractions of the licensing process pale in comparison to this area. Formal action methods and summary of disciplinary actions are summarized in Tables 4 and 5, respectively.[11]

Importance of the monitoring process by state medical boards is complicated and labor intensive. Physicians in the state of Ohio with substance-related legal charges are typically monitored for a five-year period and are required to complete tasks, which may include but are not limited to mandatory psychotherapy, aftercare substance-abuse programs, alcoholics anonymous and/or narcotics anonymous meetings, and residential substance abuse treatment programs. There are international meetings for healthcare professionals sponsored by International Doctors in Alcoholics Anonymous (IDAA), dedicated to providing support, fellowship, and resources for recovering health professionals worldwide. IDAA is a group of approximately 4,700 members of doctoral level members who assist one another to achieve and maintain sobriety from addictions.[12]

As psychiatrists, it can be challenging but equally rewarding to treat another physician in a psychotherapy relationship. The identification that occurs from physician to physician in the transferential relationship is unique and can serve to reinforce the therapeutic alliance.

References
1. Gold MS, Byars JA, Frost-Pineda K. Occupational exposure and addictions for physicians: Case studies and theoretical implications. Psychiatr Clin North Am 2004;27(4):745–53.
2. Kumar P, Basu D.
Substance abuse by medical students and doctors. J Indian Med Assoc 2000;98(8):447–52.
3. Hughes PH, Brandenburg N, Baldwin DC Jr, et al. Prevalence of substance use among US physicians. JAMA 1992;267(17):2333–9.
4. Hughes PH, Baldwin DC Jr, Sheehan DV, et al. Resident physician substance use, by specialty. Am J Psychiatry 1992;149(10):1348–54.
5. Brooke D, Edwards G, Andrews T. Doctors and substance misuse: types of doctors, types of problems. Addiction 1993;88(5):655–63.
6. Alves HN, Surjan JC, Nogueira-Martins LA, et al. [Clinical and demographical aspects of alcohol and drug dependent physicians.] Rev Assoc Med Bras 2005;51(3):139–43. Epub 2005 Jul 4.
7. Lutsky I, Hopwood M, Abram SE, et al. Use of psychoactive substances in three medical specialties: Anesthesia, medicine and surgery. Can J Anaesth 1994; 41(7):561–7.
8. Hollender M, Ford C. Dynamic Psychotherapy. An Introductory Approach. Washington, DC: American Psychiatric Press, Inc. 2005.
9. Fry RA. Substance abuse by anesthetists in Australia and New Zealand. Anaesth Intensive Care 2005;33(2):248–55.
10. Brumbaugh C, Fraley R. Transference and attachment: How do attachment patterns get carried forward from one relationship to the next? Society for Personality and Social Psychology 2006;32(4)552–60.
11. State Medical Board of Ohio. Available at: www.med.ohi.gov/pdf/statistics/statistics-disciplinary.pdf. Access date: February 5, 2008.
12. IDAA (International Doctors in Alcoholics Anonymous). Available at: www.idaa.org. Access date: February 5, 2008.

Category: Mental Disorders, Past Articles, Psychiatry, Psychology, Psychotherapy Rounds

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