Sexual attraction in the client-therapist relationship: legal and ethical issues

¶ … Consent and Framework of the Therapist/Client Relationshi

Ethics and Legal Standards in the Therapist/Client Relationship

It is patient-based needs that bring a patient and a clinical therapist together, and, together, they have work to accomplish, which will hopefully bring about a higher level of satisfaction to the patient's life. That higher level of satisfaction cannot be achieved by a therapist who becomes intimately involved with his or her patient. Standards of ethics and law in conducting oneself as a therapist have been established by peer review professionals with input from legal advisory sources, and the standards and rules are intended to keep the therapist and the patient physically and mentally safe, and to protect the patient's confidentiality and privacy. It is these ground rules that provides the basis of trust that is tangential to the therapist/client relationship in order that together they are able to work through those issues that has caused the patient to seek professional guidance in his or her life. This study examines the therapist/client relationship and the ethics and legal ground rules upon which they conduct their relationship.

Informed Consent

Informed consent is described by Ellen B. Braaten and Mitchell M. Handelsman (1997) as:

legal, ethical, and interpersonal process whereby professionals talk with clients and obtain their consent to a proposed treatment (Appelbaum, Lidz, & Meisel, 1987). Historically, the doctrine of informed consent began in medicine and was developed to assure patients' rights regarding medical treatment (Andrews, 1984). In medical practice, the issue of what information to provide to patients is considered in terms of either the reasonable person standard or the professional practice standard (Beauchamp & Childress, 1989; Bremer & VandeCreek, 1991; Gillett, 1989). Prior to 1972, the professional practice standard, whereby physicians are obligated to disclose information that is traditionally disclosed by a community of doctors, was the unquestioned standard of disclosure (Beauchamp & Childress, 1989; Faden & Beauchamp, 1986). Because doctors (as opposed to patients) decided what information to disclose to their patients, this approach was considered paternalistic in nature and reflected the high esteem in which physicians were held in the community (p. 311)."

That physicians were held in such high esteem by their patients reflects the level of confidence that arises out of the patient/physician relationship. That relationship is special, because it normally involves a patient who is suffering, either mentally or physically, some malaise for which they are seeking medical care. This causes the patient to be psychologically and physically vulnerable. The physician comes to represent something greater than the patient's self; almost a god-like entity as might be perceived by the patient because of their reduced physical or mental ability to function in their life.

Now we can begin to understand why the professional relationship that is established between the therapist and the patient is, from the immediate start, one that needs to be clearly defined and conducted so that the boundaries of professional guidance to personal improvement can be established. Ignoring those boundaries is dangerous to the therapists' professional status, and to the best interest of the patient.

The Environmental Framework

In 1952, says Carol a.V. Holmes (1998), a new term was introduced to the therapeutic community; it was "framework (p. 9)." The term came to represent to the therapeutic community the therapeutic setting in which a therapist/client conduct their work (p. 9).

It suggests a basic structure that outlines, limits, and defines the therapeutic environment and relationship, thereby distinguishing it from other kinds of environments and relationships (p. 9)."

Holmes refers to the clinical work of Dr. Robert Langs, whose communicative approach to psychotherapy is one that places emphasis on the framework, or the ground rules, in a clearly defined way (p. 10). Holmes suggests that it is necessary for the framework to be discussed in order to put it into its most clear and concise form of understanding between the patient and the therapist (pp. 10-11).

Langs considers that patients are generally highly perceptive, sensitive, and vigilant to any modifications by the therapist. He asserts that most patients require, on an unconscious level, a stable, consistent set of therapeutic ground rules: "The deep unconscious system expresses an extremely consistent and evidently universal need for an ideal set of ground-rules" (Langs, 1988, p. 135). The extent to which the therapist deviates from these ground rules is considered implicitly to inform the patient of the therapist's personal and interpersonal difficulties that are influencing and disturbing the interaction (pp. 10-11)."

What it Means

Clearly, the professional and legal communities have gone to great lengths to establish the aforementioned standards of ethics and framework for the therapeutic environment and conduct of practice. In case it remains somewhat obscure as to why, then this is the moment, as Langs has contended, for clarity. The following patient's comments are reflective of what the ground rules and framework are intended to help prevent.

H]e said that he loved me. He said that he would help me to feel like a woman.... I felt like it was part of my treatment.... I felt comfort and solace.... I worshipped Dr. F____, and I felt he had all that was good and that was healing.

A woman who had sex with her analyst. Board of Registration in Medicine v. Joel Feigen, M.D (Bohmer, C., 2000, p. 11)."

Having sex with a person whom a therapist is contracted with, by virtue of the process of informed consent, is not appropriate. That this needs to be said is in and of itself astounding; but time and again the issue surfaces and the debate as to the extent to which a therapist might go in the name of "healing" is renewed. Carol Bohmer (2000) puts into clinical perspective the above quotation taken from her book.

A quote that begins this chapter illustrates several possible frames of reference; sex between the therapist and his female patient was seen by her as treatment, healing, solace (medical care), love (gender roles), and worship (power relations) (p. 11)."

Public Response

The public, that body of individuals from which the patient roster of the therapist is created, was surveyed by Beverly E. Thorn, Nancy J. Rubin, Angela J. Holderby, and R. Clayton Shealy (1996). Using two very easy-to-read brochures, one general and the other specifically about therapist/client intimacy, the group distributed both brochures to a test group. The group concluded: