Committee: Discipline
Decision Date: 08 Sep 2020
Summary:
On September 8, 2020, on the basis of an Agreed Statement of Facts on Liability, the Discipline Committee found that Dr. Shapiro committed an act of professional misconduct in that: he committed an act of professional misconduct in that he engaged in conduct or 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; and, in that he failed to maintain the standard of the profession.
FACTS
BACKGROUND
Dr. Shapiro is a 61-year-old psychiatrist with a sub-specialty in child and adolescent psychiatry who received his certificate of registration from the College of Physicians and Surgeons of Ontario (the “College”) on August 7, 1987.
At the relevant time, Dr. Shapiro was in private practice at an office in Toronto, Ontario.
Between approximately May 26, 2014 and the end of June 2014, Dr. Shapiro provided psychiatric treatment to Patient A.
FACTS
The College Received a Mandatory Report
On May 6, 2015, the College received a mandatory report from a Staff Psychiatrist at the Centre for Addiction and Mental Health, (“CAMH”), who had assessed Patient A in the CAMH Emergency Assessment Unit.
The College Subsequently Received a Public Complaint
On February 3, 2016, the College received a public complaint from Patient A, regarding his former psychiatrist, Dr. Shapiro. At the time of the complaint, Patient A was 28 years old. It was ultimately determined by the College that Patient A was the same patient referred to in the May 6, 2015, mandatory report from a Staff Psychiatrist at CAMH.
DISGRACEFUL, DISHONOURABLE OR UNPROFESSIONAL CONDUCT
Patient A’s Psychotherapy with Dr. Shapiro
Patient A contacted Dr. Shapiro in approximately April or May 2014 asking for an appointment. Dr. Shapiro telephoned Patient A late on a Friday evening and an appointment was made for an initial assessment. Following an initial assessment conducted on May 26 and 28, 2014, Patient A began seeing Dr. Shapiro for sessions several times a week. Patient A was 26 years old at the time. The treatment included a few one-on-one appointments but mainly consisted of having Patient A participate in group sessions involving other patients of Dr. Shapiro. The group sessions sometimes included psychiatry residents. Dr. Shapiro invited Patient A to attend group sessions after the completion of the initial assessment.
As set out below, Dr. Shapiro’s overall behaviour and clinical approach made Patient A feel uncomfortable, isolated and emotionally distraught. The CAMH psychiatrist who made the May 2015 mandatory report to the College stated that this culminated in Patient A’s admission to the CAMH Emergency Department.
At the initial assessment conducted by Dr. Shapiro, Patient A started crying. Dr. Shapiro directed Patient A to look him in the eyes. Patient A found this interaction very uncomfortable as it was difficult to look into Dr. Shapiro’s eyes while crying. Patient A was particularly vulnerable at this point in his life. He was experiencing anxiety. He trusted that Dr. Shapiro would assist him with his difficulties and provide emotional support. At the conclusion of the initial assessment, Dr. Shapiro diagnosed Patient A as suffering from chronic post-traumatic stress disorder, and documented various stressors, including anxiety and social isolation.
Patient A was disturbed by Dr. Shapiro’s clinical approach during group sessions which included the use of terms such as “begging” and “commanding”. Patient A found this confusing and unsettling. Patient A understood that he needed to “beg” or “command” the attention of other group members or Dr Shapiro to Dr. Shapiro’s satisfaction, and that if he did, Dr. Shapiro would provide positive reinforcement. Dr. Shapiro failed to explain the rationale for this technique to Patient A, who was confused and disturbed by this practice. Patient A felt that he did not have the opportunity to simply discuss his concerns with Dr. Shapiro given that most of his sessions were with a group.
On one occasion, Patient A tried to get Dr. Shapiro’s attention in a group session by calling out Dr. Shapiro’s first name, “Solomon”, twice in a loud manner. Dr. Shapiro appeared to become irritated and made Patient A feel as if he could not participate at that time. Patient A broke down in tears in front of the group.
Another technique used by Dr. Shapiro was called “Words”, a form of “mindful communication”. In this technique, Patient A was told to use words to describe his feelings. On at least one occasion when Patient A tried to express his feelings, Dr. Shapiro disagreed with the words Patient A used and with Patient A’s interpretation of his own feelings, leaving Patient A feeling unvalidated and embarrassed.
Dr. Shapiro made some inappropriate comments to Patient A, that contributed to his confusion and distress. On one occasion, Dr. Shapiro referred to “the spirit”, which Patient A took as a religious reference that made him uncomfortable.
Dr. Shapiro hugged Patient A in his office, a hug that was not welcomed by Patient A.
Festival Trip
In the summer of 2014, Dr. Shapiro informed Patient A that he would be taking a one-week vacation and that Patient A should make a plan for what he would be doing thatweek. Patient A became anxious at the thought of Dr. Shapiro’s absence as he had been attending sessions 4-5 days per week with Dr. Shapiro and felt very dependent.
Towards the end of the week, Dr. Shapiro told Patient A that he was attending a festival north of Toronto, and suggested that it might be good for Patient A to attend. Dr.Shapiro told Patient A that, if he attended, they would not be spending time together at the festival and other attendees would not know that he was Dr. Shapiro’s patient. Dr.Shapiro told Patient A that if anyone asked, Patient A could be vague and say he knew Dr. Shapiro from Toronto.
Patient A travelled alone to the festival.
Patient A approached and interacted with Dr. Shapiro on numerous occasions at the festival. On a couple of occasions, Patient A approached Dr. Shapiro for counselling and support. On both occasions, Dr. Shapiro responded in a frustrated and impatient manner, resulting in Patient A doubting himself and feeling unworthy of being supported or helped. At one point, Dr. Shapiro criticized Patient A for swearing, stating that he (Dr Shapiro) was being undermined in his own efforts to stop swearing by the fact that Patient A was swearing.
During the festival, Dr. Shapiro saw Patient A dancing with and kissing a woman. Dr.Shapiro made a comment to Patient A about this interaction. Patient A recalls the comment as being along the lines of, “oh that must have been terrible.” Dr. Shapiro recalls making a comment based on his concern about Patient A becoming involved with someone he had just met. Patient A was confused by Dr. Shapiro’s comment as his sexuality had never been in issue and he became worried about Dr. Shapiro’s boundaries and wondered if Dr. Shapiro was attracted to him.
Patient A attended several workshops run by Dr. Shapiro at the festival. Patient A also attended a workshop on gender identity that Dr. Shapiro said might be good for him to attend. This again confused Patient A as his gender identity was not in issue. During the festival Patient A experienced a pattern of Dr. Shapiro withholding his attention from Patient A until Patient A behaved and communicated in a manner approved by Dr.Shapiro. Another workshop was devoted to hugging (i.e. how to navigate hugging,including when it is not wanted). Dr. Shapiro hugged some participants in theworkshop, but not Patient A, leaving Patient A feeling as if he had displeased Dr.Shapiro.
After the gender identity workshop, Dr. Shapiro spoke with Patient A using inappropriate phrases along the lines of, “your sentences are not short enough”, and, “I’m a servant of God, use me.” The religious connotation disturbed Patient A, as did Dr. Shapiro’s frustration and impatient tone of voice. Patient A tried to use the “begging” form of communication to ask for help, saying “please help me”. Minutes later, Dr. Shapiro walked away from Patient A. Patient A felt abandoned.
Patient A broke down crying uncontrollably. Patient A was given help by a member of the festival’s Health and Safety team. Another festival attendee also came to help. Dr.Shapiro soon attended in the area where Patient A was being helped. The member of the festival Health and Safety team and the other attendee left when Patient A had settled down.
Later that same day, Dr. Shapiro requested that Patient A discuss with him in his vehicle what had occurred. Patient A accepted Dr Shapiro’s invitation. Patient A told Dr. Shapiro that he did not feel safe around him. Dr. Shapiro said, “We are climbing a mountain together, and you’re just going to give up now?” Patient A got out of the car and walked away.
Relationship after the Festival
Dr. Shapiro called Patient A within two days after he left the festival and encouraged Patient A to come in for another appointment. Patient A told Dr. Shapiro that he still did not feel safe around him. He finally agreed to see Dr. Shapiro but later changed his
mind.
Patient A did not attend any further appointments with Dr. Shapiro.
Summary – Disgraceful, Dishonourable or Unprofessional Conduct
Dr. Shapiro engaged in disgraceful, dishonourable or unprofessional conduct towards Patient A, including by:
- hugging Patient A
- suggesting to Patient A that he attend a festival where Dr. Shapiro would be in attendance;
- suggesting to Patient A that he conceal the nature of their doctor-patient relationship at the festival;
- being frustrated and impatient with Patient A on occasion at the festival when Patient A sought his help;
- not responding adequately to Patient A’s distress at the festival;
- criticizing Patient A for swearing based on Dr. Shapiro’s own desire to stop swearing;
- using imagery with religious overtones, and;
- making comments that were unprofessional and misplaced.
FAILURE TO MAINTAIN THE STANDARD OF PRACTICE OF THE PROFESSION
Report of Dr. Taras Babiak
The College retained a Neuropathologist and Psychiatrist, Dr Taras Babiak, to provide an independent opinion. On February 25, 2019, Dr. Babiak provided his report to the College. In his report, Dr. Babiak opined as follows:
1. Did the care Dr. Shapiro provided to the patient meet the standard of practice?
“The care that Dr. Shapiro provided to the patient did not meet the standard of practice of the profession.
As the patient’s Psychiatrist Dr. Shapiro failed to consider the patient’s fragilities and vulnerabilities in deciding what sort of experiences to implement for the patient, for the purpose being therapeutic, namely exposure to individual and group therapy. When the patient reached out to Dr. Shapiro for help in dealing with his emotional turmoil at the [festival], Dr. Shapiro kept pushing him away, injuring the patient further emotionally, motivated out of concern by Dr. Shapiro for the patient’s potential for “outing” the nature of the relationship to others. While Dr. Shapiro may have been concerned about confidentiality in this instance, I believe he was more concerned about his boundary crossing with the patient being revealed.
With regard to boundary crossings, these occurred as well prior to the events of the…festival. There was his rather over-familiar and flippant response to the patient’s expression of admiration and idealization for him. There was late Friday night call to initiate contact with the patient, his inclusion of the patient to “sit in” in group, individual and couple sessions, after only a handful of sessions with him following his assessment -another series of serious boundary crossings. Offering the patient the choice of attending a festival where Dr. Shapiro would be present, as well and leading events, and then instructing the patient that he needed to keep the nature of their relationship to himself,was a very serious boundary crossing. While not sexual in nature, it is a violation of boundaries. It is a violation, in my opinion, because the patient was engaged by him in colluding with his Psychiatrist with what should not have occurred according to the Profession’s standards of conduct. While it is up to Physicians to maintain their professional obligations and conduct with respect to confidentiality, it is up to our patients to choose whether and whom they wish to reveal their relationship with a Physician to. It is not the Physician’s place to insist that patients protect their crossings or violations a boundary.”
From the standpoint of documentation, however, his records lack documentation of the lion’s share of what contacts his patient and he had, and what he exposed his patient to.This clearly falls below the Profession's standard with respect to clinical documentation.”
2. Did Dr. Shapiro’s care display any or all of the following:
lack of skill?
“Yes, Dr. Shapiro’s care did displayed [sic] a lack of skill in that he displayed a lack of ability to:
(a) exercise patience and restraint in his expectations for progress and outcomes in the treatment of patients with Post-Traumatic Stress Disorder. He addressed his remedial efforts and intentions with regard to his therapeutic hubris in his letter of response to the patient’s complaint and the Appendix.
(b) in the application of skills regulating his countertransference in response to Patient A's idealization of him and his reaching out to him for support in a context that the patient was unfamiliar with. Dr. Shapiro had set this problem up by offering the patient the choice of attending the festival, after having “sit in” in sessions with other patients. He first made him feel included, special and chosen,
and then he betrayed his trust, abandoned and pushed him away, making him feel diminished and discardable. Dr. Shapiro was reacting instead of responding in a considered manner, with the patient’s emotional well-being in mind.”
lack of judgment?
“Yes. Dr. Shapiro displayed a serious lack of judgment in the commission of boundary crossings with the patient in other patients’ sessions, in his boundary violation regarding his requiring the patient keep the nature of their relationship to himself at the festival to
protect his Psychiatrist's duty of confidentiality. In so doing, he retraumatized and overburdened the patient. First, he retraumatized the him [sic] by effectively rejecting and abandoning the patient the way his father had. Second, he overburdened him the way his mother had by putting the obligation to look after his Psychiatrist’s duty to confidentially after having been rather loose with these boundaries in the clinical context. The patient,feeling that he had “fallen from grace”, fell into a turmoil with psychotic reaction, and ended up in hospital.”
3. Does Dr. Shapiro’s clinical practice, behaviour or conduct expose or is likely to expose his patients to harm or injury?
“No, I believe they no longer do at this point. Given the insight, admissions and acknowledgement of how he injured the patient and could pose risks to other vulnerable patients that Dr. Shapiro details in his response letter and the remediation efforts that he lists…I cannot say he still poses a risk. He has done this in the identified areas of deficiency in his clinical work and documentation. This is encouraging, in particular with regard to boundary issues, their importance and management, where Dr. Shapiro has done course work and ongoing supervision. His continued work, consultation and supervision which he described with regard to boundary issues are and will be crucial for facilitating the transfer of knowledge and skills in considered clinical judgment and safe clinical practice.”
PENALTY
The Committee ordered and directed:
- Dr. Shapiro is to be reprimanded
- Dr. Shapiro’s certificate of registration is to be suspended for a period of six (6) months, commencing from October 1, 2020 at 12:01 a.m.
- The Registrar is to impose terms, conditions and limitations on Dr. Shapiro’s Certificate of - Registration related to related to practice supervision and re-assessment
- Dr. Shapiro is to pay costs to the College in the amount of $6,000 within 30 days of the date of the Order.