During a recent blog , I presented two case histories which I thought might stimulate different points of view on how to react to the situations described . I asked two  colleagues if they would respond . Today I will restate the first case and then I will present their views. I will also print comments from readers  I encourage anyone therapist or not to weigh in on these cases in the comment section .

Case #1

The patient is a 26 year old young women who came into therapy because she was depressed about her inability to complete things. She had started college twice and dropped out and as a adolescent she came home from sleep away camp twice. Her goal was to go to nursing school some day in the future. She had many friends but had trouble keeping a boyfriend, She was attractive but was somewhat inhibited and only on occasion would allow herself to have sexual relations which she would enjoy. Her parents were divorced when she was 6 years old. Her father is a physician would visit her periodically as a child and when she was older she would visit him and his new wife . She always felt close to them and their two children. Her own mother was an alcoholic and when she was younger her behavior was quite erratic. At time she was physically abused by being slapped around. Other times she would have to take care of mother by making food for her and sometimes would even stay home from school . Despite poor attendance she got good grades. She herself does not drink or take drugs. She shows no evidence of a major depression or psychotic symptoms. She is often moody but doesn’t appear to have hypomania. She becomes angry when she is disappointed. As a preadolescent she saw several therapists and she had 2 or 3 brief trials of therapy in the past 3 years including several weeks of a trial on an SSRI which she didn’t feel made any difference. She is currently in treatment with psychodynamically oriented psychiatrist who has decided not use medication at present. She has been coming for 4 months 2x/week ( Tuesday and Friday). She says this is the first time she is making progress in therapy as she feels she can talk freely and is not being judged.

During her last session on a Friday very close to the end of session, she said , Whatever we say here is completely confidential, isn’t it?” The therapist replied, “Why do you ask this question ?” The patient then went on , “ You know that baby sitting job that I have been doing every Saturday nite for Mr. and Mrs. Woodman my neighbor’s 15 month child.?” Well last week the kid was a real problem. He was whinning all the time and wouldn’t listen to me. The final straw was that he spit on me. I lost it and slapped him real hard across the face. His face got really red and swollen. I put some ice on it. I will never do that again.” The therapist, was stunned and before she could say anything, the patient said , “Well, I know my time is up” and got up and left.

Should the therapist do anything with this information. Is the therapist required to notify anybody? What are the legal and therapeutic implications ?

Response from invited discussant Myron L. Glucksman, M.D. Dr. Glucksman is a psychiatrist and psychoanalyst practicing in Redding Connecticut and New York City. He is a Clinical Professor at N. Y. Medical College and a training analyst at the Psychoanalytic Institute at N. Y. Medical College.

In my opinion, the therapist has no legal obligation to report the slapping incident because, so far, it is an isolated episode and apparently did not result in a serious injury to the child. The therapist should explore the patient’s feelings about her behavior; in particular, her angry feelings when she feels disappointed. I suspect that her anger is, in part, connected to her feelings of rejection and abandonment by her alcoholic mother. Evidently, she was not adequately nurtured as a child, and was exploited by both her parents in regard to having to take care of her mother. As a babysitter, she again finds herself in a similar position and becomes enraged when the child spits on her – re-stimulating feelings of rejection and humiliation. However, I believe the therapist should warn her of the legal consequences of similar abusive behavior toward the child or others in the future.

Response from invited discussant Sheldon Frank. M.D.

Dr. Frank is a child and adult psychiatrist practicing in South Florida.

There is no doubt that the information must be reported to the state child protective services immediately, with, of course, communication to the patient that this is being done. The legal and ethical mandates are clear, regardless of effects on the therapy. The therapy may perhaps be unaffected or strengthened–though not necessarily. Certainly a therapeutic relationship which covers up a reportable abusive act and denies the possibility of future risk to this child or other children being cared for by the patient does not help her in the long run. The outburst of violence on her part was so impulsive, so over-reactive to the baby’s acting like a baby, that even her sincere conviction that she won’t do it again is suspect. In addition to dynamic interpretation, the patient might benefit from other psychiatric treatment tools. Her life pattern, her complaint about not finishing things, and, perhaps, this outburst, may reveal adult ADHD (a continuation of childhood ADHD). (One can’t say from the data in this case, but ADHD children are much more likely to be slapped, neglected, and/or abused than other children.) A trial on stimulant medications is a safe and effective way both of confirming the diagnosis and treating. Alternatively, a search for mood swings and bipolarity might establish a mood-based origin of her action, and a mood stabilizer could help her self-control. We child psychiatrists often confront these diagnostic alternatives, and usually opt to test first the ADHD possibility because of the rapid onset and cleaner side effect profile of stimulant medications.

Since the account came out at the end of the session a day before the next baby-sitting engagement, there is a quandary as to how and when communicating the report mandate to the patient is handled. Some state laws require a report within 24 hours of receiving the information–which is defined as information containing the suspicion of abuse/ neglect. (It is the agency’s job, not the therapist’s, to distinguish between abuse and, say physical discipline.) Hopefully, the child protective agency would act promptly. Professionals have the right to anonymous reporting, so the agency would not tell the patient the source of the report–it could have come, after all, from the child’s parents. Still, the chance of the therapeutic relationship being damaged is greater if the therapist waits until the Tuesday session to deal with this complication. If I were the therapist, I would call the patient and ask her to return the same day to continue the session, and use that extra time (? without extra charge) to communicate to her the necessity of reporting. The therapist didn’t answer directly the patient’s question on confidentiality; if pressed, he could have reminded her that the only exceptions were situations in which there was the danger of harm to herself or others.

Initial comments from readers of this blog :

Well, when you said “dilemma” you meant it. In the first case, it weighs the betrayal of trust of a confidential relationship for someone who appears to be genuinely interested in changing her anger responses, against the safety of a very young child from abuse. My response given the details here would be to file a CPS report, and talk to the patient about the legal reasons why that had to be filed in a candid way and trying to help her see the situation through several points of view. Though it would be tragic if the therapeutic relationship were not strong enough to withstand this, a child’s safety must take precedence.- Heather Fretwell

Responses and opinions from any readers of this blog are welcome and will be added as comments. The second case will be discussed in a future blog