Tales from the Couch

Seeing the patient from psychiatry’s perspective

A Boundary Violation

Sex therapy

I was in a restaurant having lunch with some psychiatrist colleagues. As is often the case, we talked about our practices, psychotherapy, medications, and other issues relating to the field of mental health. One man, a guy who fancied himself a bit of a bon vivant, made an interesting comment.

“I have this woman patient who’s extremely seductive.”

“Welcome to the club,” said another therapist.

“She has a terrible sex life with her husband…it’s virtually non-existent.”

“What do you think is behind it?” I asked.

“I don’t know,” he said. "But I’m very tempted…”

“Tempted? How?”

“It would be the easiest thing in the world to have sex with her.”

Two other colleagues and I exchanged glances. “Have sex with your patient?” one asked with widened eyes.

“Every therapist can be tempted by some patients. It’s part of the landscape. But sex with a patient…? You can’t be serious.”

“I am. She’s seriously considering having an affair with a guy in her office. It could be terribly destructive if she did…”

“And if she had sex with you?” I asked, barely believing my ears.

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“Actually, it could be therapeutic, he said.”

Therapeutic?” asked a colleague, nearly choking on his sandwich. “How?”

“Well, it would prevent her from getting involved with an office colleague. That could have disastrous repercussions at work; and in her relationship with her husband. It could get very sticky and complicated.”

“And sex with her therapist wouldn’t get complicated?” I asked. My incredulity was difficult to contain. I inwardly dubbed this guy Lothario.

"Well…” he said, “With me, the relationship would have specific times and certain boundaries. It would be controlled.”  

“But it’s a serious boundary violation,” said another colleague.

“This whole thing about boundary violations is overblown,” Lothario said.

“But you’d be taking advantage of the transference,” I added.

“I’m not sure of that,” he replied.

“You’re not sure? She no doubt views you as someone from her past—maybe a powerful father figure. And you’d be taking advantage of a power disparity in the relationship. It’s malpractice…and in some states, having sexual relations with a patient is viewed as criminal. A therapist can be charged with rape…as though he’s an adult having sex with a child.”

“The law is arbitrary,” Lothario countered. “And it could be therapeutic for her.”

“Therapeutic?” asked a colleague. "Sounds like you want your needs satisfied. How’s your sex life at home?” he asked, not so jokingly.

“That’s none of your business,” said Lothario. “And I think it would be therapeutic for her.”

“Let me ask you something,” I said. “What does your patient look like?”

“Oh…she’s tall, with blonde hair and blue eyes…Scandinavian-looking. In fact, she was a model in her twenties…now she’s 35.”

“So, she’s good-looking…?”

“Very good looking,” he said.

I nodded my head. “Let me ask you this…” I paused.

He looked at me quizzically.

“Do you do this kind of therapy with your ugly patients, too?”

He turned beet red as the rest of us laughed.

Mark Rubinstein, M.D., is a former professor of psychiatry at Cornell. His most recent book is the novel Mad Dog House.

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