The emotions generated by therapy are so potent and lasting that
some therapists think the ban on sex should continue indefinitely. "A
patient should be forever off limits," says Glen Gabbard, M.D. "Even
after the professional relationship has been terminated, the same
feelings are immediately reestablished if they get back together."
Neglecting such a ban could gravely corrupt the therapy itself. A
therapist or patient who envisions fulfillment of longings somewhere down
the road is unlikely to be entirely open and honest. "You can't do
therapy when you're withholding information or keeping secrets to make a
good impression because you might want to date later," says Gabbard.
Symptoms may miraculously vanish when consummation awaits the end of
therapy.
Many in the American Psychiatric Association share his view. Right
now, their ethical code calls sex with a former patient "almost always"
wrong, and a proposal to remove the "almost" is close to approval.
Other experts, however, call the lifetime ban unrealistic and
probably illegal. "The constitution guarantees freedom of association,"
says Gary Schoener. The evidence of harm is ample enough to justify
abridging that right to forbid sex during therapy, but not afterward.
What's more, the vast majority of misconduct complaints occur when sex
begins immediately after termination; by six months, all but one percent
have been filed.
Minnesota and other states forbid sex for two years after therapy.
One year would probably be enough, he says.
Many professionals marry their former patients, Schoener points
out. A survey of 101 therapists found that most (with the exception of
psychoanalysts, who take transference feelings more seriously) didn't
consider such behavior unethical. "There's no evidence these marriages
don't work," he says.
But on this score, too, some remain dubious. Often, observes Rina
Folman, Ph.D., the original power imbalance remains throughout the
marriage. "The patient stays the patient. And I've seen cases where the
therapist goes on to have affairs with other patients."
BUYER BEWARE
While many offenders are inferior clinicians whose sexual
misconduct fits into a pattern of general incompetence, a disturbing
number are eminent experts at the top of their profession.
This includes those who have every reason to know better. A
researcher whose pioneering work helped document the extent and harm of
sex in therapy was later sued for divorce and ousted from his psychiatric
association for having an affair with a patient. The American Psychiatric
Assocation expelled Charles Culver, M.D., for exploiting a patient
through a personal relationship. He was professor of psychiatry and
ethics at Dartmouth Medical School, and the editor of a book on medical
ethics.
Ideally, the taboo against sex should be discussed explicitly when
therapy begins. Given the discomfort that both patients and therapists
feel around this issue, a brochure can make sure it's not forgotten. In
one state, California, psychotherapists are obligated to give patients
such a brochure at the first session.
This approach seems effective. Beverly Thorn, Ph.D., found that
after reading a brochure, current and prospective patients better
understood what is and isn't appropriate in therapy. They felt they'd be
more assertive if a therapist did something to make them uncomfortable,
and were more confident in their ability to deal with sexual misconduct.
Despite therapists' fears, the brochure didn't undermine trust. Patients
said they were less likely to file a false complaint than they were
before.
If you're in therapy, it's important to know that sexual
exploitation rarely comes out of the blue. "Sexual misconduct usually
begins with relatively minor boundary violations, which often show a
crescendo pattern," psychiatrists Gutheil and Gabbard point out in an
article in the American Journal of Psychiatry (Vol. 150, No. 2). "A
direct shift from talking to intercourse is quite rare; the 'slippery
slope' is the characteristic scenario." Regard the first slips as warning
signs.
o In a typical sequence, the relationship first changes from a
last-name to first-name basis. "There may well be instances when using
first names is appropriate, but therapists must carefully consider
whether they are creating a false sense of intimacy that may subsequently
backfire," they write.
o Next, conversation turns increasingly from the clinical to the
personal. For therapists to talk unduly about themselves should warn of
potentially dangerous departures from their proper role.
o Body contact often follows, beginning with friendly pats and
progressing to hugs. Therapists should initiate nothing more intimate
than a handshake, the authors advise, and gently discourage patients'
attempts at closer contact.
o Trips outside the office are the most common next step.
o "Sessions during lunch are an extremely common form of boundary
violation," the authors say. "This event appears to be a common way
station along the path of increasing boundary crossings culminating in
sexual misconduct."
o Patient and therapist may then get together for movies or other
social events--a familiar dating pattern before they move on to
bed.
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