Individual risk factors for physician boundary violations: the role of attachment style, childhood trauma and maladaptive beliefs

Childhood trauma, posttraumatic stress disorder symptoms, early maladaptive schemas, and schema modes: a comparison of individuals with obesity and normal weight controls

BACKGROUND

Previous research on the psychological mechanisms of obesity has primarily focused on acute psychopathology. However, there is limited literature on the role of more complex and entrenched psychological processes in weight management. The current study aimed to expand previous research by examining more enduring psychological constructs, including early maladaptive schemas (EMS), schemas modes, and trauma.

METHODS

Participants (N = 125) comprised adults with normal weight (n = 40) and obesity (n = 85) from community and clinical settings in Australia. Eligible participants completed a series of self-report questionnaires via Research Electronic Data Capture (REDCap). Two, separate, one-way multivariate analysis of variance (MANOVA) were conducted to examine group differences on the outcome variables.

RESULTS

Findings indicated a significant effect of group on EMS and schema modes, V = .51, F(32, 92) = 2.97, p < .001, partial η² = .51. Follow-up univariate tests revealed that individuals with obesity endorsed significantly more maladaptive schemas and schema modes and significantly less healthy schema modes than individuals with normal weight. In addition, results demonstrated a significant effect of group on childhood trauma and posttraumatic stress disorder (PTSD) symptoms, V = .19, F(6, 118) = 4.70, p < .001, partial η² = .19. Subsequent univariate tests and chi-square analyses indicated that individuals with obesity reported significantly more childhood trauma as well as significantly more PTSD symptoms within the last month than normal weight individuals.

CONCLUSION

This was the first study to compare EMS and schema modes in treatment-seeking individuals with obesity and normal weight controls using the short form version 3 of the Young Schema Questionnaire and revised, 118-item, Schema Mode Inventory. Overall, findings revealed that individuals with obesity experience more complex and enduring psychological difficulties than normal weight individuals. Increased assessment and targeted treatment of these underlying mental health concerns may contribute to a more holistic conceptualisation of obesity and could improve the long-term success of weight management.

Schizophrenia: a classic battle ground of nature versus nurture debate

Much has been learned about the etiology and pathogenesis of schizophrenia since the term was first used by Eugene Bleuler over a century ago to describe one of the most important forms of major mental illness to affect mankind. Both nature and nurture feature prominently in our understanding of the genesis of the overall risk of developing schizophrenia. We now have a firm grasp of the broad structure of the genetic architecture and several key environmental risk factors have been identified and delineated. However, much of the heritability of schizophrenia remains unexplained and the reported environmental risk factors do not explain all the variances not attributable to genetic risk factors. The biggest problem at present is that our understanding of the causal mechanisms involved is still in its infancy. In this review, we describe the extent and limits of our knowledge of the specific genetic/constitutional and non-genetic/environmental factors that contribute to the overall risk of schizophrenia. We suggest novel methods may be required to understand the almost certainly immensely complex multi-level causal mechanisms that contribute to the generation of the schizophrenia phenotype.

Adverse childhood experiences and early maladaptive schemas in adulthood: A systematic review and meta-analysis

BACKGROUND

Schema Therapy is based on the theory that trauma and neglect in childhood lead to early maladaptive schemas and psychopathology in adulthood. The aim of this review was to evaluate support for this theory by synthesizing the literature on childhood adversity and schemas.

METHODS

A systematic review and meta-analysis were completed in compliance with PRISMA. PsycInfo, CINAHL and PubMed were searched to identify eligible studies that reported unadjusted association(s) between adverse childhood events and schema scores when participants were 18 years or older. Meta-analyses were conducted to estimate the pooled effect size of associations between schemas and experiences of childhood adversity.

RESULTS

A total of 33 studies met inclusion criteria and provided sufficient data for meta-analyses on childhood experiences relating to toxic frustration of needs (emotional neglect and physical neglect) and trauma and victimization (emotional abuse, physical abuse and sexual abuse). Of the 124 meta-analyses, 65 indicated that schemas show small to large correlations with emotional neglect (range: r = .16 [Failure] to r = .51 [Emotional Deprivation]); small to moderate correlations with emotional abuse (range: r = .20 [Vulnerability to Harm] to r = .44 [Emotional Deprivation]); and small correlations with physical neglect, physical abuse and sexual abuse (range: r = .16 [Vulnerability to Harm] to .26 [Emotional Deprivation and Social Isolation]).

CONCLUSIONS

Of the 33 included studies, only one used a longitudinal design. However, based on the correlational studies available, early maladaptive schemas in adulthood are associated with a history of childhood abuse and neglect.

Predicting boundary violation propensity among mental health professionals

Despite its clear importance, there have been very few empirical investigations of boundary violation propensity among mental health professionals. The present study explored the relationships between self-reported propensity for boundary violations and predictors theorized to increase their likelihood. Australian mental health professionals (N = 275) completed an online questionnaire battery including demographics, the Sexual Boundary Violation Index, Boundaries In Practice Scale, Boundary Violations Propensity Questionnaire, Marlow-Crowne Social Desirability Scale, Circumplex of Interpersonal Problems, Brief Inventory of Pathological Narcissism, Barratt Impulsiveness Scale Brief Version, Satisfaction with Life Scale, Brief Experiential Avoidance Questionnaire, Adverse Childhood Experiences Questionnaire, and the Interpersonal Reactivity Index. Regression analysis was used to identify unique predictors. Boundary violation propensity was associated with nurturant interpersonal styles in females and dominant interpersonal styles in males. In regression analysis, unique predictors for male boundary violation propensity were grandiose narcissism, vulnerable narcissism, self-centred interpersonal traits, and low levels of empathic concern. For females, unique predictors were impulsivity, childhood adversity, self-sacrificing interpersonal traits, and vulnerable narcissism. In addition to informing theory about those at risk of perpetrating boundary violations, the identified predictors can inform those involved in selection for training programmes and staff appointments and serve as markers for providing closer supervision.

Sexual Violation of Patients by Physicians: A Mixed-Methods, Exploratory Analysis of 101 Cases

A mixed-method, exploratory design was used to examine 101 cases of sexual violations in medicine. The study involved content analysis of cases to characterize the physicians, patient-victims, the practice setting, kinds of sexual violations, and consequences to the perpetrator. In each case, a criminal law framework was used to examine how motives, means, and opportunity combined to generate sexual misconduct. Finally, cross-case analysis was performed to identify clusters of causal factors that explain specific kinds of sexual misconduct. Most cases involved a combination of five factors: male physicians (100%), older than the age of 39 (92%), who were not board certified (70%), practicing in nonacademic settings (94%) where they always examined patients alone (85%). Only three factors (suspected antisocial personality, physician board certification, and vulnerable patients) differed significantly across the different kinds of sexual abuse: personality disorders were suspected most frequently in cases of rape, physicians were more frequently board certified in cases of consensual sex with patients, and patients were more commonly vulnerable in cases of child molestation. Drawing on study findings and past research, we offer a series of recommendations to medical schools, medical boards, chaperones, patients, and the national practitioners database.

Serious Ethical Violations in Medicine: A Statistical and Ethical Analysis of 280 Cases in the United States From 2008-2016

Serious ethical violations in medicine, such as sexual abuse, criminal prescribing of opioids, and unnecessary surgeries, directly harm patients and undermine trust in the profession of medicine. We review the literature on violations in medicine and present an analysis of 280 cases. Nearly all cases involved repeated instances (97%) of intentional wrongdoing (99%), by males (95%) in nonacademic medical settings (95%), with oversight problems (89%) and a selfish motive such as financial gain or sex (90%). More than half of cases involved a wrongdoer with a suspected personality disorder or substance use disorder (51%). Despite clear patterns, no factors provide readily observable red flags, making prevention difficult. Early identification and intervention in cases requires significant policy shifts that prioritize the safety of patients over physician interests in privacy, fair processes, and proportionate disciplinary actions. We explore a series of 10 questions regarding policy, oversight, discipline, and education options. Satisfactory answers to these questions will require input from diverse stakeholders to help society negotiate effective and ethically balanced solutions.

Explanatory paradigms for professional boundary violations

In this commentary, I draw on Hook & Devereux to explore the role of insecure attachment in boundary-violating doctors. I also explore the potential contribution of personality dysfunction in that small proportion of doctors who breach professional boundaries.

DECLARATION OF INTEREST

G. A. worked with Dr Hook at St George's Hospital, London, and has also worked at the Clinic for Boundaries Studies, where he has worked.

Sexual boundary violations: victims, perpetrators and risk reduction

Sexual boundary violations by healthcare professionals is a subject that has largely been ignored in the UK. There has been little research into the field. It is rarely taught on professional training courses and practitioners appear to know very little about it. The history of sexual boundary violations is littered with failures to notice, failures to report and inadequate justice for victims and perpetrators alike. Perpetrators are commonly assumed to be predators. Given the many widely reported recent events in our media of both predatory and other sexual offenders, we believe it is timely for all healthcare and other professions working with vulnerable people to take the problem seriously, to provide appropriate services for victims, evaluation and assessment of perpetrators, and sanctions that fit the crime in order to regain public trust.

LEARNING OBJECTIVES

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DECLARATION OF INTEREST

None.