Reviewing a Disciplinary Case on Suicidality, Erotic Transference, and Between-Session Communication: How do therapists hold appropriate boundaries?
Curt and Katie chat about a disciplinary case against Dr. Eric Bergeman, highlighting key ethical concerns for therapists. They explore documentation practices, therapist responsibilities, and boundary management, particularly in cases involving suicidality and erotic transference. The conversation underscores the importance of clear treatment planning, proper record-keeping, and ethical decision-making to avoid legal and professional consequences. This is a continuing education podcourse.
Click here to scroll to the podcast transcript.Transcript
In this podcast episode we talk about suicidality, erotic transference, between-session communication, and documentation
Therapists are given conflicting advice on when their duties to patients begin, how much they are expected to be available to clients outside of sessions, how they are to approach between-session communications, and how to document such communications. This episode explores a disciplinary case where the California Board of Psychology investigated a therapist’s responses to a client that filed a complaint about the therapist’s treatment.
What therapists need to know about ethical boundaries and disciplinary actions:
“I think without the notes, it’s hard to understand what the thought process was…there wasn’t a deep assessment of what was happening there.” – Katie Vernoy, LMFT
- The importance of proper documentation and clear treatment planning.
- How to respond to client suicidality in real-time, including assessment and intervention.
- Managing erotic transference with ethical boundaries and consultation.
- The role of Board of Psychology investigations in evaluating therapist conduct.
Key Takeaways from Dr. Bergeman’s Disciplinary Case:
“So, to summarize this case, it seems like good intentions and good therapy are not always necessarily the same thing.” – Curt Widhalm LMFT
- The Board of Psychology found gross negligence due to poor documentation, inadequate diagnosis, and lack of clear therapeutic boundaries.
- Dr. Bergeman failed to properly address the client’s suicidality and borderline personality disorder, leading to ethical concerns.
- Consultation with another therapist revealed concerns about Bergeman’s treatment approach and lack of structured intervention.
- The Board initially sought a fine of $103,000, later reducing it to $10,363, citing good intentions but significant professional oversights.
Receive Continuing Education for this Episode of the Modern Therapist’s Survival Guide
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You can find this full course (including handouts and resources) here: learn.moderntherapistcommunity.com/courses/reviewing-a-disciplinary-case-on-suicidality-erotic-transference-and-between-session-communication-how-do-therapists-hold-appropriate-boundaries
Continuing Education Approvals:
When we are airing this podcast episode, we have the following CE approval. Please check back as we add other approval bodies: Continuing Education Information including grievance and refund policies.
CAMFT CEPA: Therapy Reimagined is approved by the California Association of Marriage and Family Therapists to sponsor continuing education for LMFTs, LPCCs, LCSWs, and LEPs (CAMFT CEPA provider #132270). Therapy Reimagined maintains responsibility for this program and its content. Courses meet the qualifications for the listed hours of continuing education credit for LMFTs, LCSWs, LPCCs, and/or LEPs as required by the California Board of Behavioral Sciences. We are working on additional provider approvals, but solely are able to provide CAMFT CEs at this time. Please check with your licensing body to ensure that they will accept this as an equivalent learning credit.
Resources for Modern Therapists mentioned in this Podcast Episode:
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References mentioned in this continuing education podcast:
American Psychological Association. (2017). Ethical principles of psychologists and code of conduct (2002, amended effective June 1, 2010, and January 1, 2017). https://www.apa.org/ethics/code/
California Board of Psychology v. Bergemann, E. (2024), Case No. 600-2019- 000342, OAH Case No. 2022060304
Leslie, R. (2021). Duty to the Patient – When Does It Begin?, Retrieved February 19, 2024 from https://cphins.com/duty-to-patient-begin/
Younggren, J. N., Fisher, M. A., Foote, W. E., & Hjelt, S. E. (2011). A legal and ethical review of patient responsibilities and psychotherapist duties. Professional Psychology: Research and Practice, 42(2), 160.
Zhu, Y. (2024). Ethical Management of Erotic Transference: A Brief Review. In 6th APSPA International Conference 2024 on ‘Multidisciplinary Perspectives on Human Development and Learning: Navigating the Nexus of Education, Psychology, Business, Language and Philosophy (Vol. 1, No. 1, pp. 113-117).
*The full reference list can be found in the course on our learning platform.
Relevant Episodes of MTSG Podcast:
It’s the Lack of Thought That Counts: Ethical Decision Making in Dual Relationships
Risk Factors for Suicide: What therapists should know when treating teens and adults
Topic: Suicide
How Therapists Can Deal with the Crisis of the Week
How Do Therapists Manage Intense Caseloads?
An Expert Witness Weighs in on Therapist Malpractice: An interview with Dr. Frederic Reamer
How Much Autonomy Do Therapy Clients Deserve? Balancing client autonomy with therapist skill
Liability Hot Potato: Defensive Therapy practices that give clients inadequate care
Who we are:
Curt Widhalm, LMFT
Curt Widhalm is in private practice in the Los Angeles area. He is the cofounder of the Therapy Reimagined conference, an Adjunct Professor at Pepperdine University and CSUN, a former Subject Matter Expert for the California Board of Behavioral Sciences, former CFO of the California Association of Marriage and Family Therapists, and a loving husband and father. He is 1/2 great person, 1/2 provocateur, and 1/2 geek, in that order. He dabbles in the dark art of making “dad jokes” and usually has a half-empty cup of coffee somewhere nearby. Learn more at: http://www.curtwidhalm.com
Katie Vernoy, LMFT
Katie Vernoy is a Licensed Marriage and Family Therapist, coach, and consultant supporting leaders, visionaries, executives, and helping professionals to create sustainable careers. Katie, with Curt, has developed workshops and a conference, Therapy Reimagined, to support therapists navigating through the modern challenges of this profession. Katie is also a former President of the California Association of Marriage and Family Therapists. In her spare time, Katie is secretly siphoning off Curt’s youthful energy, so that she can take over the world. Learn more at: http://www.katievernoy.com
A Quick Note:
Our opinions are our own. We are only speaking for ourselves – except when we speak for each other, or over each other. We’re working on it.
Our guests are also only speaking for themselves and have their own opinions. We aren’t trying to take their voice, and no one speaks for us either. Mostly because they don’t want to, but hey.
Stay in Touch with Curt, Katie, and the whole Therapy Reimagined #TherapyMovement:
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Connect with the Modern Therapist Community:
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Modern Therapist’s Survival Guide Creative Credits:
Voice Over by DW McCann https://www.facebook.com/McCannDW/
Music by Crystal Grooms Mangano https://groomsymusic.com/
Transcript for this episode of the Modern Therapist’s Survival Guide podcast (Autogenerated):
Transcripts do not include advertisements just a reference to the advertising break (as such timing does not account for advertisements).
… 0:00
(Opening Advertisement)
Curt Widhalm 0:00
Hey, modern therapists, we’re so excited to offer the opportunity for one unit of continuing education for this podcast episode. Once you’ve listened to this episode, to get CE credit, you just need to go to moderntherapistcommunity.com, register for your free profile, purchase this course, pass the post test and complete the evaluation. Once that’s all completed, you’ll get a CE certificate in your profile, or you can download it for your records. For a current list of our CE approvals, check out moderntherapistcommunity.com
Katie Vernoy 0:32
Once again, hop over to moderntherapistcommunity.com for one CE once you’ve listened. Woo hoo!
Announcer 0:38
You’re listening to the Modern Therapist’s Survival Guide, where therapists live, breathe and practice as human beings to support you as a whole person and a therapist. Here are your hosts, Curt Widhalm and Katie Vernoy.
Curt Widhalm 0:51
Welcome back, modern therapists. This is the Modern Therapist’s Survival Guide. I’m Curt Widhalm with Katie Vernoy, and this is the podcast for therapists about the things that go on in our profession, the things that affect our practices and the way that we go about things. This is one of our continuing education eligible episodes, and very much into the law and ethics episode. So listen at the beginning and end for instructions on how to get CEs for this episode, and we’ll also include directions for that in our show notes over at mtsgpodcast.com. Now, one of the things that I have learned in doing law and ethics workshops over the course of my career is that it’s really boring when people just get up and say, here’s what the law is. So, oftentimes what I try to do is interweave a little bit of storytelling into the ways that certain things come up. There’s always kind of a little bit of a debate around when we do source cases from board hearings, boards disciplinary actions, how much that we put therapist names out there when they are accused of doing something that the board finds as being against the laws and ethics of our profession. On one hand, we think that the privacy of people, especially when they’ve been through a disciplinary action, is something that we wish no further shaming upon people. But oftentimes, when there is a very real case that is something that sparks discussion in today’s episode, two discussions, which actually sparks maybe three or four discussions. But we also have to respect that the publicly available information, this is publicly available, the public availability of it is ultimately a good thing. Katie and I have been on the board of directors for the California Association for Marriage and Family Therapists, and CAMFT has this quarterly magazine that goes out, and part of the magazine is what has been called the spider pages, where it’s a publication of the disciplinary actions of the California Board of Behavioral Sciences. And while we were on the boards, every couple of years, there was somebody who said, you know, this is shaming therapists, and you shouldn’t have this in the magazine. And oftentimes the point that I would make in these debates is: putting this information out there actually lets us know what the licensing boards are investigating, what their viewpoints are in being able to convey what are the standards of the profession. And that’s something that we’re ultimately hoping comes out of the discussion of the case today, because I think that this is a case where it’s somebody who, while they were ultimately found guilty of violating some of the standards of the profession, I don’t see things in here that are necessarily things where somebody had gone out and egregiously done things wrong. But holding a case like this up and examining it allows us to be able to see where in this case in particular, the California Board of Psychology holds the standards of care and the standards in responding to cases here. So the case that we’re discussing is one that became effective January 19 of 2024 this is from the California Board of Psychology. We’ll include a link to this document in our show notes and in our references. And this is a case against a psychologist named Dr. Eric Bergemann. It investigates a client that Bergemann was seeing between 2013 and 2017. Now I’m going to go through this case, I’m not going to read everything. This document is 65 pages long, so we’re going to go through we’re going to highlight some things. Katie knows a fair amount about this case, but she’s going to be asking some questions throughout as a way of breaking up, not just having me read disciplinary documents.
Katie Vernoy 1:11
Make it a little bit interesting.
Curt Widhalm 3:35
Make it a little bit interesting. The client who made the complaint in this I’m going to use client and patient interchangeably throughout this because in my nomenclature, I generally refer to people that I see in my practice as clients, in this document, is patients. But the client’s name is omitted in this and we’re going to get into this. So, the client began seeing this therapist as a referral from a psychiatrist, and this started in about August of 2013. Now, prior to going to the psychiatrists, this client has a history of emotional trauma from a difficult childhood, had two suicide attempts as a college student and had gone to a psychiatrist for medication treatment, a psychiatrist, Dr. Alexis Link, then referred the client to Dr. Bergemann for ongoing therapy. And this was immediately subsequent to a major social loss in this client’s life, where they kind of had social ties cut from her, from a supportive, almost surrogate family, kind of club group that she was in. The documentation by the therapist in this case does end up becoming a big thing. I’m not going to focus a lot on this while I’m giving the background here, but it does come back around to being something that’s very important. Take good notes, people. That’s ultimately what I’m going to say from the beginning of this.
Katie Vernoy 7:14
Before we start into what happened, for me in when we were talking about before we hit record. I for me, I think it would have helped to have a framing around what the eventual complaint was. The client accused Dr. Bergemann of what?
Curt Widhalm 7:30
Client accused Dr. Bergemann of, emotional, financial and sexual abuse. I did say at the top of this episode that there didn’t seem to be some kind of malicious, intentional, egregious act, and that’s why part of going through this story is something that coming to this conclusion, and it’s it’s a great point, and I’m glad that Katie brought this up here to arrive at these three things, the emotional, financial and sexual abuse aspects of this. Anything else, Katie, as I have told you, the story that is important background before we start going through the overview of this treatment?
Katie Vernoy 8:16
I don’t think so. To me, when we were talking about it, especially the you know, kind of without any framing, I had a hard time identifying anything really wrong. I think over time I was able to say, oh, okay, I can see some of these things, but it does sound pretty intense: emotional, financial and sexual abuse. And so I want clinicians to listen to it with an eye to what would you have done in these situations? Because I don’t think there’s a lot of egregious stuff, maybe a few missteps, and so we’ll get into the the assessment of it. But as as Curt is talking about it, I’d really recommend thinking about: What would I have done in that situation? How would have I behaved differently? Could you have protected yourself from this claim and determine, you know, are you doing that ethical decision making and legal decision making process that we’ve talked about before when making some of your treatment decisions? So I think that’s, that’s, I think the framing, I think it’s helpful, as we get started.
Curt Widhalm 9:21
The client got reported from Dr. Link to Dr. Bergemann, and during the first session in August 2019 the respondent basic history of noting a history of suicide attempts and assessing for current suicidal ideation. And out of this first meeting, came up with a diagnosis of major depressive disorder and generalized anxiety, which was consistent with Dr. Link’s psychiatric diagnosis. And in some of the initial sessions, the therapist had also made notes about a distant relationship with her father and that she had misconnection with the father. About two months later, there was an email from Dr. Bergemann to Dr. Link about the patient’s condition, and I’m going to paraphrase this, there’s a lot of emails involved in this case, some of them I’m not going to read verbatim, but in this particular email, Dr. Bergemann had said the client is having an extremely difficult time, is extremely hard on herself, is convinced that she’s a terrible person unworthy of anything good. And they talk a little bit about some stuff that Dr. Link had suggested and that Dr. Bergemann was going to be on vacation and that somebody else within the practice was going to cover for this case, while he was gone. Over the course of time, the need for more than one session per week emerged, and they started seeing each other twice per week, and because of this higher level of need, Dr. Bergemann agreed that the patient could email him outside of her scheduled session times and that he would respond to her emails. And he did clarify that in the event of emergency, though you need to call the office, because he will receive phone messages more quickly than he will receive emails.
Katie Vernoy 11:25
So just to kind of summarize what you’re saying and make sure that I’m catching it the way that that you’ve read it, because you’ve read this in greater depth and I’ve only heard it. So: referral from a psychiatrist, the clinician takes the case on, matches the diagnosis from the medical doctor, starts doing treatment, is consulting with the medical doctor, provides coverage while he was away, and increases sessions to twice a week because the client is having some difficulties, I think suicidality is what we’ll get into, and has offered outside of session, contact to help support the client in between sessions, talking about emails and then emergency types of communication as possible. So right here, I hear decent practice.
Curt Widhalm 12:20
You know, I agree. I think that this is so far things that many therapists are taught.
Katie Vernoy 12:28
I think the email things, I think about some therapists don’t like the email thing, but DBT has coaching calls. There’s folks that say, Hey, contact me outside a session if you need some emergency crisis response kind of stuff. So it’s it’s a little bit different than some folks do, but I think there’s a lot of folks who do have a HIPAA compliant email and say, Hey, if you need to let me know about something in between session, here’s one way you can do it.
Curt Widhalm 12:54
I think many therapists are taught things such as, when a client does show more difficult time navigating life to increase the frequency of sessions, and the increase in the number of sessions, the increase in between session contact, all of this seems to be within the intention of following something like that.
Katie Vernoy 13:18
Yeah.
Curt Widhalm 13:18
And one of the things that we’re going to get through in this episode that the Board of Psychology ended up focusing on, is where is the standard of care? And that’s something else to think about through throughout this. So, Dr. Bergemann gives permission: Hey, you can email me in between sessions, and I’ll respond. Call if it’s an emergency. The very next paragraph in the complaint says the patient is a prolific writer, and during the approximate three and a half years that she was in treatment with Dr. Bergemann, she emailed him almost daily, and sometimes multiple times per day. She also wrote articles for various media outlets, had her own blog posts to social media sites for people undergoing psychotherapy, as well as writing to multiple friends and beginning in 2016 so about three years after treatment, to a second therapist that we’ll get to later. The patient testified at the hearing that she described her mental state throughout this time in working with the respondent as acute depression, and her writings about this reflected mental anguish, anxiety, panic and suicidal thoughts. And on multiple times from August 2014 through February 2017 these emails communicated thoughts of suicide.
Katie Vernoy 13:21
So she was emailing, I’m having thoughts of suicide?
Curt Widhalm 14:53
Yes.
Katie Vernoy 14:54
How did, how did he respond to those emails?
Curt Widhalm 14:57
So for example, there’s an August 2014 email that, in part, she wrote, “I’m having lots of death thoughts again, and I just wish my life was over. It’s extremely hard to think of a reason to stay alive. I love my dog, but I know he’d be okay with my husband.” And he responded with, “I’m glad you emailed. I’m sorry to hear that things are going really rough for you right now, I want to let you know that I hear you and how painful it is. Perhaps you could try some things that we talked about, like breathing with the exhales to calm your nervous system, or laying on the floor trying to ground yourself. I hope the listening helped a little bit. Hang in there. I believe you can.”
Katie Vernoy 15:36
Okay, so I’m starting to get a little bit concerned about this now. So there was…
Curt Widhalm 15:43
Tell me your concerns here.
Katie Vernoy 15:44
I am having death thoughts, which potentially that, in and of itself isn’t suicidal, it’s dark thoughts. We all have kind of dark shadow parts and all that kind of stuff. And then there’s, I’m having trouble finding reasons to live and or to continue to live, and there’s this discussion around a being that will be okay without me. So we’re, you know, if we go back to, you know, some of the episodes that we’ve done on suicide, we’ll link to those in the show notes over at mtsgpodcast.com, I’m not hearing a lot of resilience factors, or what are the protective factors. I’m not hearing those things in this email, and I don’t know that I would respond with just an email back. I think it would, there need to be context of what was, what happens in the sessions, what are, what’s known, that kind of stuff. But I would be pretty worried about this email myself, and I would probably want to get them on the phone.
Curt Widhalm 16:46
Around February 2015, so this is about a year and a half into treatment. The patient decided to try and conceive a child with her husband. Now, sometime prior to this, without Dr. Bergemann’s knowledge, the patient had discovered Dr. Bergemann’s wife on social media, even though she had a completely different surname than Dr. Bergemann, and this client followed the wife on social media. And according to the patient, seeing photographs of Dr Bergemann’s family life, posted by his wife, spurred her to begin her own family. And during this process, she feared that taking the psychotropic drugs that were prescribed by Dr. Link were going to be things that could potentially harm her unborn child, and so she sought to wean herself off of this. Both Dr. Link and Dr. Bergemann advised against this, and they believed that she experienced significant symptoms of depression and anxiety, and they believed that those could be unmanageable if she stopped her medication.
Katie Vernoy 17:59
Okay, so she went off her medication, against medical advice, and then she also was having some deep, I mean, I’ll use an old school term, transference around social media that she was following, that her psychologist had no idea was happening.
Curt Widhalm 18:16
Correct.
Katie Vernoy 18:17
Okay, so don’t see fault with Dr. Bergemann here.
Curt Widhalm 18:22
So Dr. Bergemann ended up referring the client to another integrative psychologist named Dr. Omid Naim and this practice is described as combining herbal and nutritional treatments with the use of more traditional psychotropic medications. And this was because the client had lost confidence in Dr. Link’s ability to continue to be able to treat her effectively.
Katie Vernoy 18:51
Because the only tools in Dr. Link’s toolbox were psychotropic medications.
Curt Widhalm 18:56
That’s the way that I read this.
Katie Vernoy 18:57
Okay.
Curt Widhalm 18:59
So, Dr. Naim had tried to find natural remedies to substitute for the antidepressants and however, without the drugs, the patient’s symptoms worsened markedly, and she eventually had to restart the medications. At this time, Dr. Naim also recommended that the patient see another therapist named Will Randle.
Katie Vernoy 19:22
Okay, so we’ve had psychiatrist number one, integrative psychiatrist number two. We had Dr. Bergemann, and now we have Dr. Randle is the second psychologist?
Curt Widhalm 19:34
Dr. Randle.
Katie Vernoy 19:34
Oh, Will Randle.
Curt Widhalm 19:35
Will Randle, we’re gonna get to in just a little bit as far as some of the work that ends up going on here. Now, in August of 2016 the patient’s sister wrote to Dr. Bergemann asking for help with her sister, kind of stating, in part, I know that patient deeply values you and your support, your shared family bond. Her negative thoughts are getting so strong she oftentimes can’t see past them. All of us in the family are trying to help her. We’re continuing to work, but it’s really awkward around her. She doesn’t have people that she really trusts. What do we do” That’s basically what this email says.
Katie Vernoy 20:23
And did he respond? Did he have a release of information to respond?
Curt Widhalm 20:27
It’s not clear here, but we’re getting outside perspective information on the status of the patient’s condition here.
Katie Vernoy 20:35
Got it. So, so he’s getting a clearer sense of this is untenable. She’s not doing well?
Curt Widhalm 20:42
Correct.
Katie Vernoy 20:43
Okay.
Curt Widhalm 20:44
I generally advise people don’t have disciplinary cases filed against you in the first place. But one of the things that shows up in cases that you might want to never have your name paired with is disciplinary actions that use the word erotic over and over. And this is a case that erotic transference shows up 19 times in this…
Katie Vernoy 21:12
Got it.
Curt Widhalm 21:12
And this is traced back to an october 2013 session when the respondent says that her sexual attraction towards Bergemann started when they touched hands as they returned books to a bookshelf in I’m presuming the office.
Katie Vernoy 21:31
Okay, so you’re saying dates, and I’m getting lost. So this happened early on. This was towards the beginning. And when did she let him know about this erotic transference, like, how far into the treatment?
Curt Widhalm 21:44
So, this was about two months into treatment, and she didn’t really bring this up until much later.
Katie Vernoy 21:53
Okay, so the the transference happened early on. She disclosed it much later.
Curt Widhalm 22:02
2016. So…
Katie Vernoy 22:03
Okay, like two or three years…
Curt Widhalm 22:05
…into treatment? Yeah.
Katie Vernoy 22:06
Okay, so he did not know about it for almost two thirds of the time they were working together?
Curt Widhalm 22:14
Yeah, according to this complaint that after the session where they touched hands returning books to the bookshelf she had walked down the hallway out of the respondent’s office, he called out to her and asked whether she thought she would be okay while he was away for his week’s vacation. That was the one that we had referred to earlier that he had talked with Dr. Link.
Katie Vernoy 22:33
Got it.
Curt Widhalm 22:34
In the wake of that session, the patient maintained that she experienced an orgasm lasting for five days.
Katie Vernoy 22:41
Oh, wow. Okay.
Curt Widhalm 22:43
She, by her own accounts, did not reveal the sexual attraction that she developed to Bergemann until two years later, in an email in April of 2016 where she wrote him, stating, “I feel physically and emotionally attracted to you. That’s it. That’s what I’ve been trying to say.” And in his replying email, Dr Bergman wrote, I’m glad you’re taking this brave step to share your vulnerable feelings with me. It’s important and powerful that you’ve done this. We’ll talk about it more tomorrow, but I want to let you know that it’s okay that you shared this with me.
Katie Vernoy 23:13
That seems like a decent response.
Curt Widhalm 23:16
Agreed. It seems like a healthy modeling of boundaries is as far as a response within the context of that particular snippet.
Katie Vernoy 23:27
Yes.
Curt Widhalm 23:28
Now, when the patient came to the session the next day, she was not able to talk about the sexual attractions that she was feeling. She sent another email a couple of weeks later stating, “I’m feeling such intense regret about sharing the feelings that I shared this week. I feel so incredibly heavy hearted and sad today, and I’m scared about how bad I feel.” And just a few minutes later, the respondent replied, “It doesn’t actually change anything in reality between us, we can talk further about the feelings you’ve shared, which, in my view, are normal, understandable and welcome to explore further by talking together about it in therapy. It sounds like an important part of the therapy process and getting closer to your true humanity.”
Katie Vernoy 24:09
So his response about the sexual or the erotic transference seems positive, but the I’m scared at how bad I feel was not addressed.
Curt Widhalm 24:22
And again, this was all done over email.
Katie Vernoy 24:24
Yeah.
Curt Widhalm 24:24
And in the complaint, this says that the respondent only kept basic notes about his sessions with the patient from the beginning of treatment until March of 2016 and this was around the time that the patient had sent the email disclosing our feelings for him, and during this period, the only documentation that the respondent had of treatment was the email exchanges between them, as well as the email exchanges that Bergemann had had with Will Randle. We’re still going to get to Will Randle later.
… 24:59
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Curt Widhalm 25:00
So, months go by without the patient talking about her sexual transference during their sessions, and the respondent did not ask the patient about it. Sometime in Fall of 2016 the patient started to broach the subject again, and writing in her emails that these strong feelings of attraction were physically painful, pulling her toward continuing to come to sessions, even as she was having doubts about how well therapy was working and her depression symptoms getting worse.
Katie Vernoy 25:32
So in session, she’s not able to talk about it. He doesn’t force the topic, and she’s able to express herself in email. But this email is especially concerning. It’s saying the feelings are painful, and I’m feeling like I need, like kind of compelled to come to session, even though I don’t know that therapy is helping.
Curt Widhalm 25:57
Yes.
Katie Vernoy 25:58
Okay. How did he respond to that? Because that is that’s pretty intense to think about.
Curt Widhalm 26:04
It’s not clear what the response is directly to that one, but the overall tone says that starting in September of 2016 patients emails reflected even more distress than usual, and there were more descriptions of physical symptoms accompanying her mental anguish. For example, October 5, 2016, she wrote “I was hoping to feel better today after yesterday’s session, but I’m so anxious I can barely breathe, and the choking and squeezing sensations and throat and heart are worse than ever.” Respondent continued to send messages of reassurance and reminders. Still have opportunities to discuss her feelings in upcoming sessions.
Katie Vernoy 26:42
And then the notes are not super indicative of what was addressed in sessions.
Curt Widhalm 26:50
Correct.
Katie Vernoy 26:51
Okay. So kind of placating. This isn’t a conversation for email, but then no clear sense that it’s been conversation in sessions.
Curt Widhalm 27:00
Correct.
Katie Vernoy 27:01
Okay.
Curt Widhalm 27:04
So, Dr. Bergemann also encouraged the patient to write out her sexual feelings and fantasies, believing that the expressions would bring the patient closer to an authentic sense of herself and help alleviate her depression and anxiety. According to the patient, however, continued exploration and expression of these feelings only temporarily relieved her symptoms and sometimes made her conditions worse, including increasing her suicidal ideations. In an email dated October 7, 2016, so this is two days after the previous one, “I feel even lower than usual right now, just sad and lonely and profoundly helpless. I don’t feel alive at all. Feel dark and trapped in a life that I hate and there’s no way out,” so on and so forth.
Katie Vernoy 27:47
So, he had switched to a kind of almost a text based therapy, saying, write these things out, since you can’t say them to me. But also, it seems like the theory there was, if you write them out, you’re squaring off with them, and it should relieve symptoms, but also help you become more your authentic self.
Curt Widhalm 28:09
And I’ve explored interventions like this before with some clients, not necessarily about transference issues, but just as kind of an exposure of not being afraid of feelings, and have found really, really good success with this when it’s lined up well and again, I don’t necessarily see any bad intention with what’s going on here, nor is it an intervention that is particularly egregious in and of itself.
Katie Vernoy 28:44
Yeah, and then there was this response that comes in that says, I’m feeling way worse.
Curt Widhalm 28:49
Yes.
Katie Vernoy 28:51
Which might suggest, let’s take a different tactic.
Curt Widhalm 28:54
And a different tactic was taken in November of 2016 just a few weeks later, when the patient was exceptionally agitated during her session, and the respondent, Dr. Bergemann, suggested that they do a grounding exercise that involved cupping hands, meaning he held his hands out, palms up. The patient put her hands palms down on top of his they did this while sitting on the floor across from each other, holding the position for two or three minutes while she attempted to synchronize her breath to his slower, calmer, one.
Katie Vernoy 29:27
That is very personal for someone who is expressing strong erotic transference. There’s the facing each other, sitting close together, touching hands and syncing breaths like that is very intensely intimate. Okay, all right, not a choice I would make.
Curt Widhalm 29:54
January 2017, another email, “My heart has been squeezing so tightly all the time the last few days, I know I can’t leave my son behind, because it would be so cruel to him, and I can’t be cruel to him, but I also can’t stop fantasizing about getting run over by a car, and what a relief it would be for all of this to be over.” This email goes on say “something happened after a session on Tuesday when I went all numb after you said you only wish for my well being during your break, and you felt no physical desire for me at all. The old feelings of physical revulsion towards myself crept in, and now it’s all over my body, like the way that Pepto Bismol coats the troubled stomach and that old commercial.”
Katie Vernoy 30:35
That’s that’s a very vivid metaphor there. Okay.
Curt Widhalm 30:40
That was the beginning of 2017 Okay. Also unknown to Dr Bergemann is that the patient had begun seeing Will Randle in March 2016, so this is about nine months before this particular email that I just read.
Katie Vernoy 30:59
Okay.
Curt Widhalm 31:00
The patient did not inform Dr. Bergemann about her treatment with Will Randle until October of 2016 she did not disclose her feelings to Will Randle about her feelings about Dr. Bergemann until 2017. So there’s two therapists working here Will Randle did tell her that she should stop seeing Dr. Bergemann. It’s ultimately a destructive relationship, and seems like part of the notes say that it’s like drinking poison and hoping to feel better.
Katie Vernoy 31:38
Okay, so we’ve got Dr. Bergemann seeing the client. Now, Will Randle comes on board. So, it sounds like Will Randle knew that there was another therapist and was trying to resolve that, so trying to eliminate any duplication of services. And I’m assuming they was some nod to doing different things, but Dr. Bergemann didn’t know about Will Randle for eight or nine months, and Will Randle did not know about the erotic transference with Dr. Bergemann until pretty far into treatment as well. Okay.
Curt Widhalm 32:12
Yeah.
Katie Vernoy 32:12
So, there’s stuff going on that’s not great, but some of it is due to a lack of disclosure by the client, right?
Curt Widhalm 32:20
Yeah. So the client didn’t allow for Will Randle and Dr. Bergemann to consult with each other for about six months of treatment. So, there wasn’t any permission that was granted by the client in this case. It’s also worth noting here that part of Will Randle and his specialties is addressing therapeutic impasses. So this is probably a pretty logical step on behalf of the client, as far as going somebody, why isn’t my therapy working? And Will Randle in this does testify that transference is a thing that happens. Sometimes it’s something that can be resolved super successfully. Sometimes it’s unambiguous and something that does need to be cut off. I’m very much summarizing.
Katie Vernoy 32:42
Which is good. We’re about halfway through the episode. We probably still need to get get moving through it, because it’s a long, long case.
Curt Widhalm 33:29
Eventually, Will Randle and Dr. Bergemann consulted, they exchanged emails, consulted in person, about their respective treatment, and in this Will Randle, more or less says, Hey, you seem to be doing some, you know, good therapist kinds of things, but you’re not sufficiently addressing this client. And this needs to be something that’s very crucial, especially through this transference dynamic. So the final stages of therapy going to early part of 2017 here, before her last session with Dr. Bergemann, the client, wrote, “I feel like the only power I have at all is to step away for a month, even though it’ll hurt so much. I already hurt so much all of the time. I feel so powerless most of the time and thoughts about you occupy so much of my time and energy, I just don’t know what else to do.” And Dr. Bergemann responded, “I think it’s very wise of you to notice your desire to take a break from therapy. If you feel it’s the way that you have to do things perhaps we can discuss on Friday. There’s another way to make that happen in session. For example, you make some of the rules within our sessions. What you might want to have happen. Perhaps we can come to a middle ground.”
Katie Vernoy 34:49
Okay. So. Will Randle is saying you’re potentially causing harm.
Curt Widhalm 34:56
Yes.
Katie Vernoy 34:57
The client is saying, I only have power, the only power I have is to step away, and I’m constantly thinking about you, and I feel like this is harmful and da-da-da-da-da. And Dr. Bergemann’s response is, we can, you can set rules in therapy.
Curt Widhalm 35:12
That’s more or less what this looks like. Yes.
Katie Vernoy 35:14
Okay.
Curt Widhalm 35:15
February 2017, the client returns to what this says is all of her mental health providers, including Dr. Bergemann, and spoke in a February 15 email, “I think I probably need to stop seeing you because of pain.” I am paraphrasing again here, or picking out some specific quotes. “I’m afraid that ending therapy with you will mean I’ll never have these kinds of feelings again. Totally 100% understand that you will never be with me. You’ve made that very clear, but I don’t want to let go of this. Sorry if I made you very uncomfortable. I really didn’t intend to. I feel very sick.”
Katie Vernoy 35:58
Okay, so she initiated termination.
Curt Widhalm 36:03
She did. Dr Bergemann said seeing two therapists is unproductive. It can potentially even be harmful. You can either continue treatment with me or with Will Randle, but not both of us. And Dr. Bergemann, at this time, said that the email communication between sessions has to stop. And if she continued treatment with him, as opposed to Will Randle, they’d increase their session frequencies to three times per week, and the patient discontinued treatment with the respondent as well as Will Randle shortly after that as well.
Katie Vernoy 36:37
Okay, was there any knowledge around it? Did she ended up going to some other therapist?
Curt Widhalm 36:43
We don’t know in this complaint, and this is when that complaint that comes out, that in part, says “I’m writing to file a complaint against Dr. Bergemann for the years of financial, emotional and eventual sexual abuse that I experienced during my treatment with him.
Katie Vernoy 36:59
Okay, so the financial abuse is keeping her in treatment when it was not beneficial. I’m assuming. The emotional abuse are the confusing boundaries potentially, and the sexual abuse is inadequately addressing the erotic transference. And then that grounding exercise. Is that what we’re is that kind of how we’re understanding it.
Curt Widhalm 37:22
Knowing that this is the part of the story, at least, what is being published here. That’s where the presumption would come in.
Katie Vernoy 37:33
Okay, because I also, obviously, there’s the duplication of services. There’s some, it sounds like some charting deficiencies. So there’s not a way for Dr. Bergemann to really defend himself and explain the rationale and what work was happening. It seems like there’s some failure to respond to the suicidality in those emails, it seems like those were pretty scary emails, and without the documentation to address that type of communication, it seems like that’s problematic. I mean, I guess he did say you can email me between sessions, and if it is an emergency, call me. So it was trusting the client would escalate the communication if she recognized it as an emergency. But it seems like there’s some pretty troubling things that she shared that the response was, okay, got it. We’ll talk about it in session vaguely, or Yeah, try your safety planning. Try the things that we’ve suggested like there wasn’t, it’s not clear, at least from what you’ve described so far, that he he really did any crisis response with her.
Curt Widhalm 38:49
The Board of Psychology in any of these kinds of disciplinary cases will oftentimes bring in a outside expert to be able to talk about a case independently. In the complaint here, the board looks at the American Psychological Ethical Principles for Psychologists, and they cited at issue in this case are 3.04 requiring psychologists to avoid harming patients. 3.10 and 10.01 requiring psychologists to obtain informed consent for treatment from competent patients. 6.01 and 6.02 requiring psychologists to create and appropriately maintain patient records. And 10.10, requiring psychologists to terminate therapy when patients no longer benefit or need services subject to providing appropriate pre termination counseling and referrals to alternate providers.
Katie Vernoy 38:49
Okay.
Curt Widhalm 38:49
Now for those of you who are taking this course and getting CEs from it, you might want to particularly pay attention or note what time of the episode that this is for one of our learning objectives. This is really around how boards and in this case, the Board of Psychology views standard of care. And this is a term that gets commonly used in a lot of the healing arts professions to mean the level of skill, knowledge and care in diagnosis and treatment ordinarily possessed by other practitioners in the field. And in looking at disciplinary cases, departures from standard of care are categorized as either simple: meaning a failure to use that level of skill, knowledge and care that a reasonably careful and prudent practitioner would use in similar circumstances, or an extreme deviation from the standard of care, meaning conduct that falls so far below the standards of the practicing community that it demonstrates the want of even scant care or conduct in which no prudent practitioner would engage.
Katie Vernoy 40:56
So that’s like gross negligence.
Curt Widhalm 40:58
Yes, and that’s actually the next line in the case is that negligence means a simple departure from the standard of care, and gross negligence means an extreme departure from the standard of care. The board retains Dr. Michelle Vorwerk to determine whether Dr. Bergemann violated any of these ethics. Dr. Vorwerk looked at all of the case materials that were submitted, and the first thing that Dr. Vorwerk says in her testimony is that the respondent failed to properly diagnose the patient’s borderline personality disorder.
Katie Vernoy 41:36
I’m not in love with that one. When you have a psychiatrist on board, and you’re consulting with them, and they have a diagnosis, and you match that diagnosis that seems like a standard of care. And she’s not met this client. How could she diagnose with borderline personality disorder?
Curt Widhalm 41:57
Dr. Vorwerk does go on to say that without having evaluated the client herself, that she can’t make that diagnosis, that somebody she never evaluated has this diagnosis. But what she does point out is that nowhere in this treatment does Dr. Bergemann take the step to rule out borderline personality as a potential diagnosis.
Katie Vernoy 42:20
Okay, so she’s seeing snippets of things that might be borderline personality disorder and suggest that his assessment is not sufficient.
Curt Widhalm 42:30
Correct.
Katie Vernoy 42:30
Okay, I still don’t love it because he matched the psychiatrist.
… 42:34
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Curt Widhalm 42:34
Amongst the other things that Dr. Vorwerk pointed out is multiple charting deficiencies, no clear treatment plan, handwritten notes dated only to reflect the year and the month. They were illegible and in parts confusing. There’s eight month gap charting that was especially egregious.
Katie Vernoy 42:57
Oh, geez, that’s horrible. Okay, this one’s legit. This is pretty bad and handwritten notes. I didn’t realize that there’s people that still do that.
Curt Widhalm 43:08
And a little bit of a sidetrack here, but in some of the law and ethics workshops that I do, and especially around things like data breaches and whether or not to trust some of the electronic health record systems, or even people who are just trying to stay outside of being anything that would fall under the auspices of HIPAA, there are a fair number of people out there who do, seemingly still take handwritten notes. I’m finding more and more board complaints, making specific citations around, Hey, you did handwritten notes, and we don’t like that.
Katie Vernoy 43:50
So that there’s a documentation demerit.
Curt Widhalm 43:56
That’s a great way of putting it. Yeah.
Katie Vernoy 43:58
If you have handwritten notes, if they’re like, super neat, and they’re super complete, maybe you’ll get by, but if it’s kind of chicken scratch that especially has serious gaps, the handwritten part is going to tank you.
Curt Widhalm 44:12
So, Dr. Vorwerk also points out that the evidence that especially when the patient was decompensating in September of 2016 when the renewed feelings of attraction to Dr. Bergemann increase along with increased distress that this was a time when Dr. Bergemann had failed to discontinue therapy, or even shown any signs of considering discontinuing therapy, and she considered that these failures constituted a departure from APA ethic standard 10.10. She did not indicate whether this was a simple or an extreme departure.
Katie Vernoy 44:52
I think without the notes, it’s hard to understand what the thought process was, but in the way that it’s been presented. It feels very much like either this was missed or was manipulated to keep this client in treatment. It’s not great. Like this part I don’t love; that, that she was clearly in distress. There wasn’t a deep, you know, assessment of what was happening there. He didn’t really address the dynamic sufficiently in sessions to render it healthy. Like it seems like it was fairly messy.
Curt Widhalm 45:32
Dr. Vorwerk also points out that while grounding exercises in general are not contraindicated, in situations such as the very specific session, ones involving touch are contraindicated because of the patient’s heightened reactivity to touch and this constituted incompetent practice.
Katie Vernoy 45:52
Yeah, that, that sounded pretty bad as you were talking about it. I agree with that finding.
Curt Widhalm 45:57
Similar to Will Randle’s testimony, Dr. Vorwerk, also agree that transference and erotic transference is neither unusual or considered a negative development, but it’s essential that therapists maintain a neutral and non judgmental position and maintain appropriate boundaries as the transference is worked through. However, if it’s not addressed appropriately in treatment, then it can become very problematic.
Katie Vernoy 46:23
She mentioned it at a point, we don’t, I don’t know exactly how far into the treatment she mentioned it, but she had a very hard time talking about it. He didn’t pursue it, and it seems like she was able to talk about it in these emails, but he wasn’t engaging in kind of a therapeutic response to the emails. And so it was kind of this half conversation, and then it seems like he tried to set a boundary, saying, I’m not attracted to you like that that’s not on the table, and that caused more harm in her eyes, because it was potentially, I don’t know, perceived as harsh. So erotic transference is challenging in the best of situations, and I think we should have an episode so we can have a an expert talk us through what to do, but having this halfway thing where there’s a lot documented that the client is saying and not a lot documented on what the therapist did, I think that there’s so much liability here and potentially a lot of harm without any proof that there was not.
Curt Widhalm 47:27
Dr. Bergemann also was able to bring an expert in and brought in Dr. Sylvia Patricia Shuttleworth and Dr. Shuttleworth, I’m going to try and go through some of these fairly quickly, so we can reach some of our conclusions here. The notes thing, I think, has been well established at this point. And part of the questions around working on suicidality, Dr. Shuttleworth and the respondent tried to make a case that in responding to the patient very quickly after these emails where suicidal ideation but not intent was expressed, might fall within areas around responsible practice. I’m paraphrasing. This is not directly here.
Katie Vernoy 48:16
Okay.
Curt Widhalm 48:17
And they argued that this met the standards of care. The grounding exercise, Dr. Shuttleworth also believed was something that, because the client had expressed for sexual attraction at this point, was something that was also should have been obvious to Dr. Bergemann here. In the response to the emails indicating your continuous suicidal ideation, because Dr. Bergemann was in frequent contact through email, which he answered properly, Dr. Shuttleworth felt that this did meet the standard of care as far as response to patients, particularly because the suicidal intent aspect was not also expressed there. So having suicidal ideation, as you mentioned even earlier, seems to be something that it’s being addressed. So Dr. Bergemann’s expert was saying, I think that this does meet the standard of care and being responsive to a client who’s in near continuous suicidal ideation.
Katie Vernoy 49:13
Okay, there’s an argument that there needed to be more response, and then I guess the proof’s in the pudding, the client did not die by suicide, so there’s, at least there were some protective factors, or sufficient response by Dr. Bergemann to be able to keep this client alive. And yet, it’s an interesting practice to to only have that suicidality discussed in emails, and I’m assuming there was some in session, and yet the documentation may not be sufficient. So was that a finding, or was that?
Curt Widhalm 49:52
So we’re gonna get to the findings here.
Katie Vernoy 49:55
Okay.
Curt Widhalm 49:55
And so the mode of psychology oftentimes in being able to fund their investigation oftentimes attaches a fine to investigation costs. Could you guess what the investigation costs were in this case?
Katie Vernoy 50:11
I have no idea. There was two experts. There’s, you know, there’s whatever the process will be to if they, if they actually, you know, said, yes, there are findings. There’s, you know, kind of the follow up cost. So I have no idea.
Curt Widhalm 50:26
So the board is seeking investigation costs the amount of $15,910
Katie Vernoy 50:32
Okay, that’s, that’s a hefty, hefty price tag there.
Curt Widhalm 50:38
Oh, we’re not done. Initial expert consultant costs of I’m gonna round these numbers to nice round numbers. The expert initial consultant costs of $1,300, the final expert consultant costs of $5,200 and enforcement costs in the amount of $81,000.
Katie Vernoy 50:58
Oh, okay.
Curt Widhalm 51:00
This totals to $103,629.85
Katie Vernoy 51:07
So Dr. Bergemann was found to be liable for 103,000 and change to start. Wow, that’s hard, because, as you have mentioned before in this episode, this doesn’t sound like malintent.
Curt Widhalm 51:28
And even with some of the oversights around some of the sexual boundaries, there doesn’t seem to be egregious sexual violations.
Katie Vernoy 51:43
Yeah, no, it was ill advised. It was poorly followed up on. But there was not this, this therapist was not having sex with his client, which is the big scary thing that people talk about, like, Oh, this is going to be, what’s going to be the big, big thing that makes everybody get in trouble. This didn’t happen here. In fact, it sounds like there were some specific conversations around this is not going to happen. Even though it felt bad to the the client, it was something where it sounds like some boundaries were at least attempted to be set. So $103,000 and change for some poor decisions, maybe some slightly messy boundaries.
Curt Widhalm 52:24
You were asking the what actually ended up happening out of this case. And by virtue of this being a publication of the Board of Psychology and being a disciplinary action, some things were definitely found where Dr. Bergemann had violated this. So the first and second causes for discipline gross negligence and repeated acts of negligence. And this covers things such as failing to properly diagnose and appropriately treat the patient, and failure to address her erotic transference to timely terminate therapy and to maintain proper documentation to treat the patient’s suicidality appropriately and to seek peer counseling for assistance with the patient’s treatment.
Katie Vernoy 53:08
Okay.
Curt Widhalm 53:10
There’s further description in here, failure to take notes, third and fourth causes for discipline: violation of the rules of professional conduct, violation of the laws and regulations governing the practice of psychology, and this again comes back to citing documentation as being unprofessional conduct and failure to maintain and record records in a way that is necessary and to the standards of the profession. The fifth and sixth causes of action: the inadequate and inaccurate record keeping and unprofessional conduct, again, is about documentation here. So, the fine in this case did not end up being $103,000. It ended up being reduced to $10,363. So, to summarize this case, it seems like good intentions and good therapy are not always necessarily the same thing.
Katie Vernoy 54:09
Yeah.
Curt Widhalm 54:09
And while this might not be something that, as we were reading through this and talking about, okay, there are some things that were done, record keeping. We didn’t want to beat that over your ears repeatedly throughout this episode. Well, that was something that was a very far departure away from the standard of care. Some of the oversights, and especially within kind of more ongoing, intense, frequent contact cases, where you can sometimes get so much into the client’s world that you fail to step back and to be able to look at how much is my counter transference into this, even when I feel like I’m setting appropriate boundaries, going to be something where I just can’t see this. All of the professional angles that I’m supposed to.
Katie Vernoy 55:03
I think this case is a really good one to look at, because so much of what ended up being problematic, aside from the documentation, which it sounds like, potentially with pristine documentation, there would have been fewer findings. So everyone, document, document, document, make sure your documentation is good, then you may be more protected. But if we look at the things that happened, we could reframe them as innovative. Here is a therapist who is working with a client who is a prolific writer, does well with writing, and is providing an avenue for this client to be able to better express herself, is sitting in the darkness with her and not getting overly excited about it, is saying, okay, yeah, I’m sorry you’re having a hard time. Keep doing what you’re doing. Let’s keep talking about this in therapy, right? It’s not like, oh my gosh, I’ve got to do an assessment on you now. We need to get a call immediately. It was, we know what’s going on here. This is you telling me, sharing the darkness, me witnessing it, and you continuing to survive. There’s sitting with all right, you have erotic transference that’s pretty normal. I’m gonna let you set the pace for how we talk about it. I’m going to be a human with you on this journey and provide treatment that, in my mind, aligns with you. But there was an email that she sent to Bergemann saying that she felt so drawn to him that she kept going to treatment, even though she didn’t feel like it was working. If that’s the case, there’s this element of there were warning signs that this was not okay. She started seeing another therapist to address therapeutic impasses that were difficult for her to talk about with her own therapist, and didn’t tell her therapist about it. But he didn’t know that this other therapy was happening for a while, and I don’t know how long he knew and it was going on at the same time, but responding to, hey, this isn’t working with: okay, we’ll try something different. I don’t think that’s far out of the realm of acceptable, but it seems like he was a little bit hesitant to say, Okay, let’s refer you out. This seems like you’re struggling a lot. He wasn’t shying away and saying, You’re too much for me, or I can’t see you because you’ve expressed these feelings of erotic transference to me. But he also wasn’t saying, what is it that is best for you right now? Do you, do you have a decision that you need help making as far as whether we continue working together or not. It seems like it was, well, of course, you’re going to continue working with me, and we’ll figure it out. When I think about this and some of the things that we’ve talked about on this podcast around innovative treatment, being a human, I can see rationalizations for some of these things, even the not so well advised grounding exercise. I can see those things being rationalized and having a rationale for them that aren’t too far out from some of the things we’ve talked about. And so to me, I feel like this is, this is a really, really important conversation. So I hope everybody’s been listening and taking notes, because there is a responsibility for clinicians to step back into more of that, maybe not sterile or medical model, but into that clinician role, and look at what is happening here, outside of what I feel is happening here. You know, what’s the consultation I need to have to make sure that this case that is more complex and maybe even messy, that I’m not getting lost in it?
Curt Widhalm 59:13
We had talked about some of the standards of care and even some of the deviations from them earlier in the episode, even amongst things such as the contact in between sessions and my practice, as a DBT practice, we end up with clients that are diagnosed with borderline personality disorder. We do have clients who don’t meet that diagnosis, that do engage in suicidality. It’s a practice that we’re comfortable in working with here, and we do encourage between sessions contact within some very specific guidelines.
Katie Vernoy 59:50
What are those guidelines?
Curt Widhalm 59:51
So with DBT coaching calls, it’s not engage with me in between sessions and sit with me through all of your feelings and just emote and emote and emote. There is a structured calling format that clients are given to say, Hey, I’m calling about this specific problem. I’m having difficulties with it. Here’s what I’ve already tried. Here’s what I’m asking for your help with from the very beginning of the call, and having that structure ahead of time really does allow for it to be active directing towards being able to solve very specific problems that are arising between sessions, not pages and pages of emails or something like that.
Katie Vernoy 1:00:44
And my understanding of of DBT coaching calls is that they’re very short. They’re like 15 minutes or or less. And I know when I’ve done quote, unquote coaching calls without that structure, it sometimes turns into a full session and is not necessarily what’s needed in the moment. So to me, I think the DBT coaching calls structure is really a very strong one to make sure that you’re doing just what’s needed for the client in that moment in between sessions.
Curt Widhalm 1:01:13
And I think it has worked wonderfully. I think the longest coaching call that I’ve taken in this kind of format is something around 14 minutes. And so very consistent, and part of it is maintaining your boundaries and your structure around: this is the way that we practice. Because we have had calls when people call in and say, I’m really suicidal right now, blah, blah, blah, And they’re not following the format that we’ve agreed upon and talked with people about from the beginning, we say, here’s the coaching worksheet, fill this out, call me back when it’s filled out, and we end the call as per the agreement.
Katie Vernoy 1:01:56
I think we could get into a whole conversation about DBT, and like some people don’t like it, because, in truth, you’re hanging up on a client who is saying they’re actively suicidal. So I don’t know that that’s in the scope here, necessarily.
Curt Widhalm 1:02:12
Sure. But when we do have people who are expressing suicidality between sessions and at the very beginning of the episode this is one of the offshoots as we’re nearing the end of our recording here, around the board of psychology’s response that merely emailing clients back about suicidal ideation is not part of the standard of care, and that this does necessitate some kind of a response back from the client that engages in real time conversation with them to assess their ongoing needs. Seems to be what the licensing boards want us to do.
Katie Vernoy 1:02:53
If we’re talking real time, and we have folks with different ways that they prefer to communicate or feel able to communicate when in crisis, are we saying that it can’t be email, it must be text, or it has to be phone call, or we have to get a session? Like we can get really in the weeds here around what’s acceptable and what’s not. I think the stronger piece of advice for this particular conversation is have clear boundaries on what the coaching calls or in between and session contact will look like and document it, including all of the planning and the agreements around what happens when you’re suicidal or in crisis and need in between session contact. Whereas I don’t believe that Dr. Bergemann did that. It doesn’t suggest that the documentation was strong enough to really show, hey, we’ve got an open agreement, that this is what’s going to happen, and this is how it’s going to work.
Curt Widhalm 1:03:53
And one that would be continuously revisited around what those practice policies are.
Katie Vernoy 1:03:58
Sure.
Curt Widhalm 1:03:58
Now, what did come up in our discussions, and this has come up in my group practice. It was brought to me by an associate somewhat recently. At what point are we responsible for responding back to clients when they do express suicidality? Now this is kind of basically a larger question and kind of tacked on for another learning objective here so, but it does bring in: Okay, if a client has expressed suicidality to you, when, when are you obligated to making these follow up phone calls? Essentially, when does your responsibility to a patient begin? And some of the literature out there that I had initially come across said that your responsibility to the patient begins at the time that they pay for the first session, which I find to be completely wrong in just about every account.
Katie Vernoy 1:03:58
Sure.
Curt Widhalm 1:03:58
Some make the argument that your responsibility begins when the first session happens. That did not come up in this particular associate’s question for me, because what had happened is after the initial phone call, when the agreement was made for Hey, it sounds like you’re working on goals, x, y and z, we can schedule a session out for three or four days later. In the meantime, I’m going to use our EHR to send you some intake paperwork and a more standard questionnaire. Please fill that out before we meet in a few days. And in this intake, the client had indicated active suicidality. The associate comes to me and says, What do I do? I haven’t started meeting with the client yet. And our response and the right answer to the question in the quiz is, Once you’ve agreed to services, your responsibility to the patient begins. And so you have agreed, hey, we’re going to work together. I think that I can help you. And now that you know that there’s active suicidality going on, even though you haven’t met this client for the first session, you should reach out to them for a real time assessment to determine their level of risk.
Katie Vernoy 1:06:26
So more relevant, I think to this case, you’ve agreed to be this client’s therapist. They fill out the paperwork, maybe you follow up if they display active suicidality in that case, but once you actively start treatment, then it’s determining with in between session contact, how quickly do you need to respond to an email or some paperwork or a text or a left voicemail in order to sufficiently respond to your responsibility around active suicidality. Because for me, I think about, I have to sleep, I have to see other clients. I have my own stuff. And then there’s also this whole thing of, I don’t always have the bandwidth to be able to respond to active suicidality. And I know DBT talks about waiting until you’re in wise mind to respond to coaching calls even. What if I haven’t read the email yet? What if I haven’t read the paperwork yet? I mean, the way around, what you just talked about is, I don’t read the paperwork for my new client until they’re getting ready to walk into my door. So, so they may have written it seven days ago, and I read it today, and they’re walking in the door. I think to me, these are difficult questions to answer, and maybe this is something that we talk about another time, but I can understand why someone would prohibit any in between session contact, if the expectation is I am always responsible for my client, even if I’m asleep, even if I’m sick and just out for the day and didn’t notify the client because they weren’t I wasn’t supposed to see them that day. Yes, I agree we are responsible for these clients once we have agreed that they are our clients. But even the nuance of how that looks, I feel like requires potentially a whole other episode.
Curt Widhalm 1:08:45
So the summary on on this one, as we close out this episode, is a licensing board would look at what would a reasonable clinician do in this scenario? Now it’s akin to an answer that I frustratingly give a lot of people when I’m providing consultation or supervision or even to some of my clients, when they ask me: How soon should I do something? or How much of something should I do? And that very frustrating answer is: the right amount. You can find our show notes over at mtsgpodcast.com. Look there for instructions on how to get CE information for this episode and follow us on our social media. Join our Facebook group, the Modern Therapist Group, to continue on with conversations and until next time, I’m Curt Widhalm with Katie Vernoy.
… 1:09:40
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Katie Vernoy 1:09:41
Just a quick reminder, if you’d like one unit of continue education for listening to this episode, go to moderntherapistcommunity.com purchase this course and pass the post test. A CE certificate will appear in your profile once you’ve successfully completed the steps.
Curt Widhalm 1:09:56
Once again, that’s moderntherapistcommunity.com.
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