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When the Licensing Board Comes A’Calling: |
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Professional Practice |
Bernard J. Lewis, Ph.D. |
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Although it may seem like a remote possibility, psychologists can be at great risk for the destruction of their career, their reputation, and their financial well-being. As a senior psychologist with 25 years of experience in my state, I was unprepared for the painful consequences of an error in judgment I made in trying to respond to the needs of an individual who sought my services. A complaint was filed, and the investigation began. Three years later, I received a report of findings that lacked factual accuracy, seemed bent on proving my guilt, selectively collected and used information to prove the case, and rendered an extremely harsh punishment. Leading experts who were knowledgeable about licensing boards and ethics and who knew something of my situation urged me to contest the licensing board’s actions, which I did for six months. Ultimately, however, I elected to surrender my license because I had reached retirement age and the costs (well into five figures) had exceeded what it was prudent to expend to continue to fight for a principle. (Peterson, 2001, p. 339) Licensing board investigations are becoming almost an “occupational hazard” or cost of doing business for psychologists in private practice. Often the psychologist knows an investigation is coming because of a client’s threat or a copy of a letter sent to a board; however, sometimes the news comes as a complete surprise. Either way, the day the investigator shows up at the office is likely to be one of the worst in the psychologist’s life. The number of state licensing board investigations has increased in most states in recent years. The majority of complaints to licensing boards are ultimately determined to be unfounded, and many never progress to the point of an investigation. However, the investigation that follows reasonable complaints, by necessity, must be thorough. The subsequent stress a psychologist endures while going through an investigation is considerable. Many who have lived through this stress have called it the worst experience of their lives. Many others label it as the most difficult experience faced in the course of their careers. Some even surrender their license and leave their chosen career rather than face the stressful experience of an investigation. A negative outcome from a licensing board investigation can be, and usually is, reported to APA, which can then begin its own investigation. Thus it is not uncommon for there to be two separate investigations to examine the actions of the psychologist, and the resulting stress to continue for three or more years. Of course, in certain types of situations a malpractice suit can also follow these investigations, subjecting the psychologist to a “triple whammy.” The stress of a malpractice suit is very similar to the stress of a licensing board investigation. The pattern of stress experienced in these situations has been labeled “litigation stress” in the professional literature. The stress of a licensing board investigation is both acute and chronic. The stress hits hard when the initial notification of the investigation arrives, then is experienced chronically over the months and years that typically pass before the investigation is resolved. There are times of an acute “flare-up” of stress, such as when a hearing date approaches, a written response is due, or just prior to a meeting with a lawyer. Thus, the harmful effects of the acute form of stress keep reoccurring over the course of many months or years. A wide variety of symptoms associated with this stress have been reported in the limited literature available and in the interviews conducted by the author. While the specific symptoms and degrees of stress encountered vary considerably, virtually every psychologist going through this experience reports moderate to severe symptoms in a variety of areas. At the head of this list is the emotional upset described by virtually every psychologist interviewed by the author. Anger, fear and annoyance were the most common initial reactions reported. Depression, embarrassment, anhedonia, and a loss of self-esteem are also common as the litigation goes on over many months and the stress takes its toll. Physical distresses such as headaches, sleep disturbance, chest pain, and gastrointestinal symptoms are often described as well. An exacerbation of pre-existing physical health problems can be expected. Rare cases of cardiac arrest in the first months after initiation of an investigation have been reported. Cognitive disruption, in the form of problems with concentration and attention, are common, especially during high-stress times. Irrational thoughts associated with “catastrophizing” and “awfulizing” are difficult to avoid. Those with obsessive-compulsive tendencies (a high percentage of psychologists) tend to get stuck on “What if….” or “If only….” Thoughts such as “If only I had gone with my instinct and not taken that referral” can be quite tortuous. Interpersonal stress in the professional practice, such as withdrawal from professional activities, isolating self from peers, and irritability with clients and office staff, is frequently described. Many psychologists refuse to work with high-risk clients or those similar to the one who filed the complaint. As a fairly natural and probably positive reaction, many practice more defensively, ordering more tests, insisting on consultations, or taking meticulous notes. Some psychologists facing an investigation feel they were shunned by peers who did not want to be associated with the “tainted” professional. Marital and family conflicts are very common consequences of litigation stress. Pre-existing strains in these relationships are magnified, and many a marriage has dissolved during or shortly after the completion of an investigation. Of course, allegations of sexual improprieties can be a big factor in this, but even when this is not an issue, the strain on a marriage is often considerable. As one would expect, it is not uncommon for the use of alcohol, tobacco, and caffeine to increase during this time of stress. This is obviously a period when there is a high risk for abuse of these substances, as well as prescription medications, especially pain medications, the anxiolitics and sleep-aids. Many psychologists report taking anti-depressant medications for the first time while facing an investigation. It appears this type of stress is especially wearing on the neurochemical system. The distressing effects of litigation stress leave lasting scars on most who go through this ordeal. A high percentage of those interviewed by the author reported they were still dealing with the emotional, physical, and interpersonal consequences several years after investigations concluded. A substantial number of individuals approached about being interviewed on this topic declined the request, explaining that the pain from the experience was still too intense, and they were not yet ready to re-open these wounds. Those psychologists who felt their treatment by the licensing board was unfair commonly reported on-going anger and dissatisfaction with the entire process as well as the outcome. Even those with no adverse findings from the investigation consistently reported the experience changed them in undesirable ways. Most psychologists, as well as other medical and mental health professionals, bear the burden of licensing board investigations with little outside assistance. While information on legal assistance is available through professional liability insurance carriers, little information is available about handling the psychological aspects of an ethics or licensing board investigation. While some medical liability insurance carriers provide limited information about coping with “litigation stress,” the APA-endorsed professional liability insurance carrier provides no information on this topic. The stresses of a licensing board investigation rarely fall on an emotional clean slate. Psychologists carry their own emotional baggage with them that will determine, in part, how they perceive and react to the threat of an investigation or suit. It is easy to believe that those with either DSM-IV Axis I or Axis II issues will find the stress to be more upsetting, and may be more prone than others to find themselves the subject of a licensing board investigation. Psychologists and other mental health professionals tend to believe that since they are trained to help others cope with stress they do not need to ask for or accept help themselves when faced with litigation stress. However, the old maxim “the lawyer who represents himself has a fool for a client” should ring a bell. As hard as it is to open up and ask for help at this embarrassing and frightening time, the utilization of a social and professional support system is the best coping technique for dealing with litigation stress. In the dozens of interviews conducted by the author, those who reported they had coped well with an investigation repeatedly pointed to the utilization of support as the factor most related to their success. Those who did not cope well frequently reported this as the thing they wished they had done differently. Many professionals have a difficult time discussing the suit or investigation with their spouse or partner when they are first notified, especially if they have made a mistake or error in judgment that prompted the litigation. If the allegation involves sexual misbehavior the difficulty is compounded. However, this is an especially important time for honesty and setting the stage for open and honest communication with this most important member of the support team. While there is some risk associated with this course of action, the vast majority of spouses and partners accept imperfection in their loved ones and rally to the cause. A negative or rejecting response from the spouse is rare, and reflects a relationship that is already in trouble. Similar hesitations and fears of rejection arise when a decision must be made about whether to inform professional colleagues and others in the workplace. While there are reports of colleagues who do not want to associate with “the accused,” it is much more common for there to be an outpouring of support and offers of assistance. Those colleagues who have themselves faced an investigation tend to be especially empathetic and supportive. Since anger, anxiety, and depression are among the most frequent emotions experienced throughout the stressful process of litigation, cognitive techniques are extremely important tools for managing the emotional roller coaster that is commonly encountered. Either on one’s own, or with assistance from a therapist, it is essential to be able to move beyond the irrational thinking and obsessive worry that easily take over in this situation. It is common for psychologists to think, “Everybody will hate/reject/lose respect for/stop referring to/ me once they hear about this.” A more rational perspective of the situation and the outcome is: “I’ll get through this. Most people will understand.” The effective use of cognitive techniques is a key and essential tool for managing this type of stress. The management of the stress-related physiological reactions involves recognition of the source of the stress, and taking appropriate prophylactic measures. Relaxation techniques such as meditation, yoga, and massage top the list of recommended activities. Consistent exercise is also a crucial element of managing the physical reactions. For those psychologists who are not already engaged in these healthy activities, getting started on them at this critical time can greatly ease the months of stress ahead. Involving one’s personal physician as a member of the stress management team can be of great assistance as well. A considerable number of psychologists facing litigation stress appropriately utilize and benefit from medication to address anxiety, depression, sleep disorders, or other physical reactions to the stress. Obviously this needs to be carefully monitored by the physician, as there is always potential for abuse or dependency with long-lasting stress of this type. Honesty with the physician about the source of the stress is another helpful step toward building a support system as well. Last, but certainly not least in importance for managing the stress of a licensing board investigation, is the benefit of counseling or psychotherapy. Especially when the psychologist has made a mistake or error in judgment that led to the investigation, entering into psychotherapy with an experienced clinician can be extremely helpful. In addition to the support and insight that may develop, voluntarily taking this action to resolve psychological issues will be perceived positively in a licensing board investigation. Even when no mistake or judgment error is acknowledged, this regular sounding board and “reality check” from a knowledgeable outsider can help ease the way through this stressful time. In addition to the individual work, marital or relationship counseling can both help avoid any relationship-damaging effects of the stress and provide a ready source of support for the partner. Both the direct and indirect outcome of an investigation will determine how long the stress continues after the situation is formally resolved. Obviously, if resolved favorably, the stress dissipates fairly quickly, with lessons learned about the ease with which one can be accused being the primary lasting effect. If the resolution is not so favorable, the stress continues with consequences on many levels. A licensing board action is likely to result in restrictions in the professional practice, a requirement for supervision, or a requirement for individual psychotherapy. Subsequent consequences with the professional liability insurance carrier, with continued or future participation on managed care panels, and with hospital privileges are likely. In these ways, the stressful consequences of the licensing board action continue over years, and require an on-going awareness of the stress and continued use of stress management techniques. The possibility of involvement in a licensing board investigation is an ever-present fact of life for clinical psychologists. It may not be possible to avoid these situations and the stress inherent in them. However, the degree to which they disrupt and interfere with one’s happiness, interpersonal relationships, physical health, and ability to work will be greatly influenced by the degree to which the professional can accept the situation, recognize the ordeal that is ahead, and utilize the help of others to best deal with the inescapable stress. Reference: Peterson, M.B. (2001). Recognizing concerns about how some licensingboards are treating psychologists. Professional Psychology: Research and Practice. 32, 339-340. |
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