Discussion of the Patient Who Slapped a Child

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

I certainly agree with Dr. Glucksman in this mater.  Dr. Franks by the book, rather concrete approach is useless and harmful, as long as the patient is cooperative and open to suggestions.  There is a question though of whether the child might need help in understanding and digesting what happened so that a traumatic scar is not left in his mind.  I might have insisted that the patient talk this over frankly with the parents and take whatever steps are needed to protect the child and see to the child’s mental health.
Arnold Robbins MD.
Cambridge, MA

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

 

 



 

 

What Should a Therapist Do in These Situations?

Being a psychotherapist is a complicated job. Not only must you be knowledgeable about human behavior, psychodynamics and various techniques of doing therapy, but you have to be prepared for unexpected dilemmas . Two cases are presented below which bring up potential legal and ethical issues as well as technical considerations, which the therapist has to take into account to best help the patient.

These vignettes are based on real cases which I have  either been involved with as the therapist or as  the supervisor or I have read about them or have been told about them by a colleague. Some details may have been changed to protect confidentiality.

All the cases are at least 10 years old. Readers of this blog are welcome to express their opinion about the cases. We all recognize that in a real clinical situations, there would be much more information available about the patient which might help in making a decision.

In a future blog, I will present further discussion about these two cases.

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 ?

 

Case #2

A senior therapist  is supervising the following case. The patient is a single 36 year old dental hygienist living in Manhattan who is in her second year of three times / week psychoanalysis. She entered treatment because of difficulty trusting men which has been related to an inconsistent and insensitive father who shared with the patient the fact that he was cheating on her mother. The therapy has been going well and the patient has made progress in her ability to accept interpretations, have her own insight and utilize insight through her understanding of the transference.

The patient came into a recent session a little anxious and perplexed. She related the following incident . The other day after coming home from work she  rode up in the elevator with a young man a few years younger than her  who lives across the hall from her with whom she has a causal acquaintance. She believes he has a minor position in the union and always viewed him as trying to act like a wannabe tough guy but “a nice kid.”  He was pacing back and forth and seemed scared and she asked if everything was Ok. He asked her if she had a beer or a drink. She invited him and gave him a beer. She distinctively heard him say half to himself, “ I can’t believe I helped put someone to sleep.” When she asked him what did he say, he said it was nothing. They chatted about incidental things and he thanked her for her time and left. She wondered if that were something serious like someone being killed but then became scared and changed the subject and got into talking about her family, dreams and other things that were all continuation of issues she had been recently talking about. The therapist didn’t see any direct or indirect references to this subject in the next two sessions leading up to the  supervisory session.

Does the supervisor t have any obligation to either to suggest  or urge his supervisee  to try to influence the patient to report this information to the authorities and  is the therapist or the supervisor  obligated to do so.? What are clinical and therapeutic implications for the therapist  to spontaneously bring up this incident if the patient is not talking about it ? 

When A Nanny Slaps a Child

A nanny tells her psychiatrist that she has slapped the 18 month old child under her care. A course of action for the therapist could include filing a report of child abuse, a Tarasoff warning to the family and an involuntary hospitalization of the patient if indicated. The possibilities of what could happen if the therapist did the above or some other action were discussed.

(Due to technical difficulties this blog was offline the previous week so therefore it will be run for an additional week)

A few years ago I heard about a resident who presented the following case to his psychotherapy supervisor. (I have changed some details for confidentiality):

Case History

The patient is a  22 year woman who is working as a nanny for a  prominent celebrity. She entered twice per week psychotherapy two months previously because of difficulty in relationships with men. She has just started to talk about how she was physically abused by her alcoholic stepmother as a child. During a recent session she appeared to be distracted and wasn’t her usual organized self. Near the end of the session she blurted out that she became very angry with the 18-month-old child that she cares for and slapped the child . She was scared she might have hurt the child but he seemed to be OK. The therapist was stunned and for the first time was at a loss for words. The patient changed the subject and spoke about another subject and then the time was up. Her parting words were that she was really glad that the therapist didn’t condemn her. She knew that she did the wrong thing with the child and will try not to do it again. She added that if the therapist had reprimanded her, she never would come back again. She feels she can trust the therapist and is now very hopeful about getting help in therapy.

What Would You Do?

Before you read further, I would like to suggest that you jot down on a piece of paper if there is anything that you think that the therapist should do. Then let us see if the discussion below changes or supports your approach.

Mandatory Reporting of Child Abuse

It is well known that the there is a bond of confidentiality between a patient and a physician which is recognized by the law. This also extends to other licensed therapists, clergy, and attorneys. Recognized confidentiality is the keystone of our ability to do psychotherapy. Patients understand that they can trust us with their deepest secrets.

In fact our patient was initially concerned about talking about her stepmother because she has a 17-year-old sister at home and she didn’t want any repercussions to occur to her stepmother who she feels has been good to her  despite the  episodes of abuse when she was younger.  Most people have awareness that a special court order by a judge is required for a doctor to turn over medical records without permission of the patient. There are situations where doctors have even refused to do so even after such a court order and have faced the consequences. In this particular case there is obviously no court order. However there are some other reasons that the psychiatrist might feel compelled to break his patient’s confidence.

In some states including New York where this patient was being treated, there is a law, which mandates physicians to report any known or suspected cases of child abuse. When such reports are filed, there would be a case file opened and an investigation is supposed to be immediately conducted. In such a case the parents who are obviously responsible for the child would be questioned to determine if they have put the child in any jeopardy. It would seem that in such a case the parents would be informed that a physician has reported suspected abuse and would obviously act accordingly.

The Tarasoff Rule

On October 27, 1969, Prosenjit Poddar killed Tatiana Tarasoff. Both had been students at the University of California at Berkeley. They had met a year earlier and  Poddar became convinced they had a serious relationship. Tarasoff told him she was involved with other men and not interested. Poddar became depressed.He talked to a friend and was eventually convinced to go to student health. He started therapy with a psychologist on staff. During his his ninth session, Poddar confided to his therapist  that he was going to kill Tarasoff when she returned from summer break. The therapist subsequently informed the campus police that he felt Poddar was dangerous and that he should be hospitalized involuntarily. The police picked up Poddar, but after questioning felt he had “changed his attitude” and released him after he promised to stay away from Tarasoff. Poddar stopped thaerapy and later went to Tarasoff’s house and stabbed her to death with a kitchen knife. He then called the police and asked to be handcuffed. Her parents then sued the psychotherapist for failing to warn them or their daughter about the danger. The California Supreme Court rejected the psychotherapist’s claim that he owed no duty to the woman because she was not his patient, holding that if a therapist determines or reasonably should have determined “that a patient poses a serious danger of violence to others, he bears a duty to exercise reasonable care to protect the foreseeable victim of that danger.” Many states including New York  followed California’s lead and now have expectations of a “duty to warn” potential victims. Under the Tarasoff Rule a therapist, therefore, does not incur any liability for breaking confidentiality to warn a victim who is in danger and is expected to do so.

Involuntary Hospitalization

If the patient were to have a serious mental illness such as severe depression with suicidal ideation or psychosis with command hallucinations, the psychiatrist could fairly  easily arrange an involuntary hospitalization for further evaluation and treatment. This apparently is not the situation in this case.

What Could Happen?

If the therapist attempted to do a Tarasoff warning, let us consider how this would work. First of call she would have to know how to reach the parent of the child to warn them. She wouldn’t necessarily have that information. In this case since the parent was a celebrity she might have some clues, but such attempted warning would no doubt involve some intermediary parties prior to speaking directly with the parents. This might involve publicizing the concern and the abuse, which might even end up in the media. This could embarrass the parents although one would think they would want to know. However, if the actual danger were exaggerated, then this could be creating bigger problems.

If the therapist were to submit a report of suspected abuse as mentioned, this would trigger an investigation, which would involve the parents. In the same way if the therapist had called the police and reported a potentially dangerous situation, the police would track down the nanny who could be caring for the child. They would have to take the child into protective custody until they located the parents  (who sometimes are out of town). Then they would turn the situation over to an agency which would investigate potential abuse.

As all the above were considered, the therapist also had to consider the strong possibility that any of above actions would most probably lead to the termination of therapy. In addition the patient who had resisted entering into psychotherapy in the past, would be further alienated from seeking help.  She would most probably obtain employment as a nanny in the future even if she didn’t have a letter of recommendation from her current employer. She interviews very well and actually had a letter of recommendation from a previous employers that would only show a two-month gap. She would then be in the same situation to potentially harm children with no one who would know about it. It is unlikely that there was sufficient evidence to support any charges being brought against the nanny that would lead to her being put in jail or hospitalized with a mental disorder.

On the other hand, the nanny could have seriously injured the child and there is an obligation to that child and any future children under her care.

What Did Happen?

The therapist ultimately decided with the assistance of the supervisor that she would not take immediate action which would lead to the patient leaving therapy and thus lose any chance of preventing this young women from abusing children in the future. During the next session two days later, she brought up the subject of her hitting the child. The patient said that she hadn’t done that again. The therapist said that she  was pleased about that but she shared the dilemma that that she would be obligated to warn the parents if she believed the child was in danger, as well as have to report abuse. She suggested that the nanny take a leave of absence for few weeks from her work which was easy to do since there were other nannies who also cared for this child . She was able to take on work which she had done before assisting elderly people where the patient had no inclinations for abuse. They agreed they would work on this problem and in the future they could decide when she was ready to return working with children. The patient was receptive to this idea and appreciated the concern of the therapist in wanting to help her and yet not get her into trouble, as well as understanding the legal and ethical obligations of the therapist.

Do You Have Any Comments On This Case

Your comments on this case are especially welcome since there is no easy answer here.