Twenty-five years ago, when Michael Kandle was just starting out as a psychologist in New Hampshire, he took on a 12-year-old patient whose mother was emotionally unstable. Meeting after a particularly harsh outburst from the woman, the child discussed with Kandle the fear and anger her actions had stirred.
A week later, he recalled, the mother approached, furious over what she had heard about the last session’s focus, and threatened to accuse him of molesting the child.
It was a jarring lesson for the novice practitioner, one that was revived last week when Concord psychotherapist Foad Afshar was convicted of groping his underage client during a session last year. The moral, Kandle said: Treating young patients is inherently risky.
“I can’t trust that the court will protect me from false allegations,” he explained, adding, “And if the court won’t help us, there’s really no better way than to just avoid the patients altogether.”
The conviction has sent waves through the state’s psychiatric community, where Afshar, 56, was well-regarded, once presiding over the New Hampshire Psychological Association. The case touches on the challenges of protecting both young patients and their providers, and could impact the way practitioners approach their work.
“I’m hoping this case will generate more discussion about how we’re going to handle these types of situations,” Kandle said. “Do I not treat (children) at all anymore? Do I install a video camera? . . . It’s a problem without a clear solution.”
Finding clinicians in New Hampshire who are willing to work with young children can be difficult. Those like Kandle, who practices in Durham, are reluctant to assume the liability of a young patient, choosing instead to focus on older adolescents and adults. Kandle sees some children, he said, but almost always with a guardian present, even though it can deter children from talking openly. He turns down those with personality disorders and whose parents are separated, divorced or in otherwise adversarial positions, as he finds them more prone to file complaints against him.
Paul Frehner, a psychologist in Peterborough, takes a similar approach. He no longer takes on patients under 13 unless it’s in a group setting, and he asks to video record sessions with potentially problematic clients.
“Risk management is part of what we do, and the notion that working with children is higher-risk is well established,” Frehner said.
Neither Frehner nor Kandle attended Afshar’s two-week trial, and neither wanted to come off as defending Afshar’s actions. Kandle has known Afshar professionally for years, he said, and was shocked when the allegations surfaced. He still struggles to reconcile the image of the man he thought he knew with that of the one carrying out such serious abuse. But both he and Frehner stressed that a patient’s trust is sacred, and should never be violated.
“That we have this place that people can come talk about issues that are really sensitive, that’s a real privelege, and I think it’s really important to protect that,” Frehner said. “This case is part of protecting that.”
Criminal cases like Afshar’s are unusual, at least in New Hampshire. Most complaints against mental health providers here involve non-criminal claims and end in either dismissal or disciplinary action by the state Board of Mental Health or the Board of Psychologists. Penalties can include everything from license revocation to suspension, restricted practice and mandatory classroom learning.
“As an organization, when this happens, there is kind of an explosion of emotion and interest and wondering and all the rest of it,” said Craig Stenslie, a Dover psychologist and the incoming president of the New Hampshire Psychiatric Association.
“What we don’t want to get lost in this,” Stenslie said, “is there is a code of ethics and certainly the welfare of our clients and of children in particular is the number one priority.”
In New Hampshire, which has around 2,700 licensed mental health workers, just under six dozen formal complaints have been reviewed by the boards since 2013 (the Board of Psychologists launched in July 2013) and only a few have been found credible. None besides Afshar’s have led to criminal charges.
Gerald Koocher, a former chief psychologist at Boston Children’s Hospital and a past president of the American Psychological Association, said it’s the first child sexual abuse case against a practitioner he can recall in years. Currently the dean of the College of Science and Health at DePaul University, Koocher said complaints most commonly involve sexual intimacy with adult clients and parents unhappy with child custody evaluations.
Koocher, who specializes in ethics and who is licensed in Massachusetts and New Hamsphire, said Afshar’s therapeutic approach with the child – using touch therapy to help rid the boy’s anxiety over an upcoming physical exam – raised questions.
“In general, there are very few well documented psychiatric therapies that require you to lay hands on a patient – of any age,” he said.
That was echoed at trial, where prosecutors questioned why, if Afshar’s intentions were genuine, would he have placed himself at great risk by taking no real professional precautions. Afshar purportedly never asked to record the sessions, took no immediate notes about them, and, most importantly, never notified the boy’s parents that he was using touch therapy. Afshar testified that he had minimal contact with the child, and mostly directed him to touch benign parts of his own body while imagining it was Afshar’s hands.
Afshar, who is appealing the felony conviction, has practiced in the state for more than three decades, and nearly four dozen people signed up to testify on his behalf, including colleagues and former patients and their relatives.
“I’m grieving for all the kids who he helped,” said one mother who took the stand and whose children have been treated by Afshar. She asked that her name be withheld to protect their identities.
“I can assure you he did not do it,” she said. “The jury got it wrong.”
False allegations do happen, but are rare, Koocher said.
At trial, Afshar suggested that the boy had made up the claim to get out of therapy, and said he was sending an email at the time the assault occurred. He also argued that he would have been in too much pain from arthritis in his hand to touch the boy in the way in which he was accused. Prosecutors countered each point, noting, for instance, that the email in question was sent minutes after the session was scheduled to have ended.
In the end, none of that necessarily mattered. While it’s unclear what ultimately swayed jurors, in New Hampshire, they can convict in a sexual assault case based on the plaintiff’s account.
Prosecutors, who have never ruled out the possibility of other victims, welcomed the guilty verdict. Afshar’s attorney, Tony Soltani, said he was so distraught by it that he was contemplating leaving the criminal defense profession.
Describing Afshar as one of the finest child therapists in the state, Soltani said, “I’m convinced this will have a serious impact on pediatric psychology in New Hampshire.”
Afshar was not actually licensed as a psychologist, but rather as a clinical mental health counselor. He achieved a doctorate in psychology through a distance-learning program at California Coastal University, but because the school is not accredited through the APA, New Hampshire does not recognize it for licensing purposes.
The concern with online programs, Koocher said, is that they don’t require enough supervised, in-person training for students. Afshar’s combined doctorate and earlier masters in education from Harvard University, “while respectful, does not train you for practice,” Koocher said.
Deborah Warner, a psychologist in Littleton who has served on the Board of Mental Health, said practitioners are rigorously vetted when applying for licensure, education being just one of several ongoing requirements.
Asked about Afshar, Warner said, “I know him professionally and respected him. Obviously many people did.”
Warner said the debate over video recording is still in its early stage, with a number of questions left to answer. Among them, she said: Will it weaken patient care? And, “Once you have a videotape, what do you do with it, and who has access?”
“It appears that the Afshar case will be bringing this to light in conversations in New Hampshire,” Warner said.
Kandle doesn’t record sessions and said he doesn’t know others who do. Instead, he tries to avoid potentially risky legal scenarios by turning down some underage clients.
“That child will have to go somewhere else,” he said, suggesting community mental health clinics as an alternative. About 20 percent of Kandle’s client base is under 18, he said.
Freher, the Peterborough psychologist, finds that underage patients require between 30 to 40 percent more work than adults. That’s partly because of the liability issue, he said, but also because guardians and usually outside entities like schools, police departments and medical facilities get involved.
“It’s definitely difficult for children to get services,” Freher said. He added, “I hear a lot of clients who’ve called five or six therapists who are full.”
But Stenslie said many clinicians still treat children, and will continue to despite outcome of last week’s trial.
“You have to step back and consider what really is the danger,” he said, referring to the risk of false allegations. “There tends to be a skewing of the perceived risk and the actual risk,” Stenslie said. “My point of view, and that of the New Hampshire Psychological Assocation, is that psychologists can and will continue to treat children, and I don’t think that’s going to change substantially.”