Previous Hearings
Committee: Discipline
Decision Date: 18 Jun 2018
Summary:
On June 18, 2018, the Discipline Committee of the College of Physicians and Surgeons of Ontario (the College) found that Dr. Paul Albert Mitchell committed an act of professional misconduct, in that: he has failed to maintain the standard of practice of the profession, he has engaged in sexual abuse of a patient, and he has engaged in an act or omission relevant to the practice of medicine that, having regard to all the circumstances, would reasonably be regarded by members as disgraceful, dishonourable or unprofessional. The Committee also found that Dr. Mitchell is incompetent.
Dr. Mitchell is a GP who has practised exclusively in psychotherapy in Ontario since 1991.
The findings against Dr. Mitchell relate to a single complainant, Patient A, who he saw as a patient for approximately 200 sessions from 2009 to 2013. Patient A initially recorded her sessions with Dr. Mitchell because she wanted to listen to them again and informed Dr. Mitchell of so doing. Later on, however, she recorded the sessions without his knowledge, because she believed that she was being criticized and demeaned by Dr. Mitchell, and was concerned that no-one would believe her.
Patient A began seeing Dr. Mitchell in 2009 because of symptoms of anxiety, depression and suicidality. Dr. Mitchell initially diagnosed the patient with mild depression and an anxiety disorder. Later on, these diagnoses evolved to a bipolar mood disorder and adult attention deficit disorder. Other diagnoses documented by Dr. Mitchell, at the end of his therapy with her, included borderline personality disorder and antisocial personality. Dr. Mitchell treated Patient A by using a therapeutic technique variously called by him “PSR” (Problem-Solving Response) therapy, “bitching and complaining therapy,” as well as “seeing sequence therapy.”
Patient A first contacted the College in 2011 regarding filing a complaint against Dr. Mitchell, but did not make a formal complaint until May 16, 2013. After Patient A had filed her complaint, she text-messaged Dr. Mitchell requesting an appointment. After exchanging a series of text-messages, Dr. Mitchell and Patient A met face-to-face in August 2013 on the grounds of a university. Thereafter, Patient A returned for appointments with Dr. Mitchell at his office, between August and September 2013. The final appointment took place in September 2013, during which Dr. Mitchell gave Patient A a letter stating that he would continue to provide medical care to her, because he never terminated a therapeutic relationship with his patients and because he never gave up on patients and he would continue to provide medical care to her, unless she instructed him to do otherwise.
Failed to Maintain the Standard of Practice of the Profession
- Failing to communicate in a professional manner, including verbal abuse, shunning, swearing and threatening to terminate the doctor-patient relationship
The Committee found that Dr. Mitchell’s therapeutic technique was abusive, unprofessional and a poor fit for Patient A. The Medical Expert retained by the College (“the Medical Expert”) expressed concerns about how Dr. Mitchell’s therapeutic technique could be of benefit to any patient. The recorded sessions were a shocking example of ignoring or ”shunning” Patient A., verbally abusing her by yelling and swearing at her and repeatedly threatening to terminate therapy with her. His use of the vernacular included repeated use of “bullshit,” “fuck” and he went so far as to say “you suck” and that there was no hope for her. In the Committee’s view, this was a glaring example of a failure to maintain the standard of practice.
- Failing to maintain appropriate boundaries including managing transference, making comments of a sexual nature, texting, permitting homework in the office and meeting Patient A outside of the office The Medical Expert opined that Dr. Mitchell failed to maintain and manage boundaries with Patient A, including managing transference and counter-transference issues and making comments of a sexual nature. Dr. Mitchell did not disagree that he encouraged Patient A when she told him of her sexual fantasies about him. Dr. Mitchell also did not disagree that he made repeated references to a “sex on a stick” dress and called her a sexy coy bitch. Dr. Mitchell excused this as needing to make a point. The Committee did not agree and found a failure to maintain the standard of practice.
Dr. Mitchell repeatedly took refuge in the premise that it was the patient who directed the therapy and that all of his therapeutic interventions were ultimately in the interest of the patient. The Committee stated that the outcome of this, given the patient’s illness, was perhaps predictable or as opined by the Medical Expert in her summation of the texting between Dr. Mitchell and the patient, “one chaotic mess.” The Committee did not accept Dr. Mitchell’s view that standards of practice are meant to be breached by physicians as “exceptions” or that standards of practice can be adapted arbitrarily to the patient with whom they are working. Standards are not to be adapted at the whim of the therapist. There are elements of courtesy, respect and decorum, all of which are part of standards, many of which were violated in this case.
There was no dispute that Dr. Mitchell met with Patient A in a park on the grounds of a university, that she did school homework during her office visits and that he failed to set a professional tone in their therapy sessions. The Committee accepted the Medical Expert’s opinion that these constituted boundary violations and a failure to maintain the standard of practice. The Committee also found that Dr. Mitchell’s therapy caused harm to Patient A, even though this was not crucial for a finding of professional misconduct.
- Continuing to provide care after Patient A had complained
Dr. Mitchell continued to provide treatment to Patient A, despite there being a clear conflict of interest after the patient had filed a complaint to the College. The Committee determined that his continued involvement with the patient after she had filed a complaint was self-serving on the part of Dr. Mitchell. He admitted in his testimony that he intended to build a record against the patient on the subterfuge of continuing her therapy. During this time, Patient A had other physicians who were providing care to her. The Committee accepted the Medical Expert’s opinion and found that Dr. Mitchell failed to maintain the standard of practice of the profession in continuing to provide care to Patient after Patient A complained to the College about his care.
Disgraceful, Dishonourable or Unprofessional Conduct
The Committee found that Dr. Mitchell engaged in disgraceful dishonourable or unprofessional conduct in his care and treatment of Patient A.
Dr. Mitchell verbally abused Patient A including: use of profanity; repeatedly threatening to terminate therapy; allowing and at times encouraging crossing of professional boundaries through extensive text messaging which blurred the doctor-patient relationship; and failing to properly manage transference and counter-transference. He made comments of a sexual nature. In engaging in this conduct, Dr. Mitchell disrespected Patient A and did not act in her best interest.
Dr. Mitchell placed himself in a conflict of interest with Patient A when he continued to treat and communicate with her after she had made a complaint about him to the College. It should have been readily evident to him that this would be highly improper. Yet he continued to communicate with her for some months and made references when texting with Patient A, to a professional death penalty and not being “tit for tat.” In doing so, Dr. Mitchell acted in his own self-interest and not in the interest of Patient A, who was already seeing physicians for her medical care.
Sexual Abuse
The Committee determined that Dr. Mitchell engaged in behaviour or remarks of a sexual nature. The behaviour and remarks were not appropriate to the medical services that Dr. Mitchell was providing to Patient A.
Patient A developed a sexual transference towards Dr. Mitchell. Dr. Mitchell encouraged her, telling her to enjoy her fantasies. Dr. Mitchell did not dispute this and it is recorded in the medical record of Patient A.
Dr. Mitchell introduced the term “sex on a stick” during treatment sessions to describe the patient’s manner of dress and behaviour and in one session, called her a “sexy coy bitch.” During one session where Patient A brought a dress to her session with Dr. Mitchell, he suggested that she try on her “sex on a stick dress” and then suggested she did not have to try it on because it would obviously highlight her “breasts and butt.” The Committee saw no therapeutic value in Dr. Mitchell’s sexual remarks to Patient A and found that they were inappropriate to the services that he was providing to Patient A.
The Medical Expert opined that the use of the term “sex on a stick” was a sexual comment about the patient’s appearance. She opined that the exchange between Patient A and Dr. Mitchell about her dress was one where Dr. Mitchell was making sexualized comments about the patient’s appearance. The Committee accepted this and found that the evidence of Patient A, the clinical records, Dr. Mitchell’s own admissions and the Medical Expert’s opinion established that Dr. Mitchell made comments of a sexual nature to Patient A and therefore engaged in sexual abuse.
Incompetence
The Committee found that Dr. Mitchell is incompetent in that he demonstrated a lack of knowledge, skill or judgment in his care of Patient A, and demonstrated disregard for her welfare.
The Medical Expert made reference to the patient’s diagnosis and stated that treatment should have been driven by the diagnosis. Dr. Mitchell’s record made no reference to the patient having a borderline personality disorder other than as opined by psychiatric consultations completed by another physician in March 2010 (this consult being requested by Patient A’s family doctor, not Dr Mitchell, and reassessed in September 2011). Patient A testified that Dr. Mitchell had told her that she did not have a diagnosis of borderline personality disorder. Dr. Mitchell’s chart contained one mention of borderline personality disorder, in August 2013. Chronologically, this was at the end of her therapy sessions with him which began in 2009. Dr. Mitchell did not appear to understand the nature of his patient’s mental disorder that brought her to treatment.
The Committee acknowledged that Dr. Mitchell appeared to have a detailed understanding of his therapeutic technique. It was unclear, however, whether he was aware that the patient continually struggled to understand and implement his technique through its five-year course. Further, the Committee saw the therapeutic technique as quite complex and was not persuaded that it was applicable to patient treatment in general or appropriate to Patient A. The Committee noted that Dr. Mitchell continues to utilize this therapeutic technique with his other patients. At the hearing, he strongly defended his use of his therapeutic technique with Patient A, despite objective evidence to its harm.
Dr. Mitchell repeatedly attempted to put responsibility on the patient and take little responsibility for problems encountered in the therapeutic relationship, holding rigidly to his model of therapy. This rigid adherence to his therapeutic model appeared to blind Dr. Mitchell to some very troubling aspects of the sessions where boundary violations, transference and counter transference, and sexual comments were noted. The Committee recognized that the therapeutic interaction between a physician and patient is one of a power imbalance. It is the responsibility of the physician to control, guide, and manage the therapeutic interaction. In the end, management of the patient’s symptoms is the responsibility of the physician: it is not the responsibility of the patient. Patients come to their physician because they are ill and seek help.
The Committee found that Dr. Mitchell’s lack of knowledge, skill or judgment is of such nature that he is incompetent. The Committee finds that he poses a risk of harm to patients.
On September 28, 2018, the Discipline Committee ordered and directed that:
- the Registrar revoke Dr. Mitchell's certificate of registration effective immediately.
- Dr. Mitchell appear before the panel to be reprimanded within thirty (30) days of the Order becoming final.
- Dr. Mitchell reimburse the College for funding provided to patients under the program required under section 85.7 of the Health Professions Procedural Code, and shall post an irrevocable letter of credit or other security acceptable to the College to guarantee payment of such amounts within thirty (30) days of the Order becoming final, in the amount of $16,060.00.
- Dr. Mitchell pay costs to the College in the amount of $54,180.00 within thirty (30) days of the date of this Order.
Decision: Download Full Decision (PDF)
Hearing Date(s): Motion Date: March 24, 2017
Hearing Dates: April 10 , 12,13, May 30, 31, October 24, 27, 31, November 1, 2, December 7, and December 15, 2017. Penalty hearing date: September 28, 2018