Análisis externo

Sexual intimacy with discharged patients has, until recently, been little debated in the literature, and many surveys do not differentiate between sexual contact with current and discharged patients.

In a study which did draw a distinction between current and former patients (Gartrell, Herman, Olarte, Feldstein and Localio, 1987), 29.6% of respondents stated that they believed that post termination sexual contact with patients would sometimes be acceptable. Interestingly, 74% of the psychiatrists in this study who had had sexual contact with patients believed that such contact would be acceptable, and indeed used this as a means of rationalising their behaviour. Indeed, it is possible that therapists may terminate treatment in order to engage in sexual contact with patients (Coleman, 1988a). In a brief report of another survey, Derosis, Hamilton, Morrison and Strauss (1987) state that the overall rate of sexual contact with patients reported by their psychiatrist respondents was 6.6%, whereas if post termination cases were dropped, the rate fell to

6

1

In a survey of complaints regarding inappropriate sexual behaviour filed to U.S. state licensing boards and psychological ethics committees between 1982 and 1983,

Chapter 1 Critical Review of the Literature 18

psychologists were held in violation even when sexual contact with patients began following termination of therapy (Gottlieb, Sell and Schoenfeld, 1988). In fact, one psychologist was deemed to be in violation when beginning a sexual contact with a patient whose therapy had been terminated four years previously. Gottlieb et al (1988) also note that, at least for North American psychologists, their professional liability insurance extends to former patients with no time limit in respect of monetary settlements for sexual impropriety. In Britain, the situation is less clear. The British Psychological Society professional liability insurance policy would determine the extent to which a sexual relationship between a former patient and a psychologist could be said to be a consequence of the business or profession of the psychologist. If the relationship is considered as such, then the policy would only provide cover against spurious allegations. If the relationship is not considered as such, no cover would be provided (Johnson, 1996, personal communication).

In legal terms, at least in some states in the U.S.A., the psychotherapist-patient relationship is held to continue in perpetuity for the purposes of the issue of sexual misconduct (Folman, 1991). This supports the view that sexual contact between a psychotherapist and a discharged patient is inappropriate, since the initial therapeutic encounter permanently and irrevocably establishes the prohibition against therapist- patient sexual contact on an "ethical contract" basis (Herman, Gartrell, Feldman, Olarte andLocalio, 1987).

Many of the reasons discussed in Section 1.2 for rejecting the legitimisation of sexual contact with current patients are equally applicable to those who have been discharged.

Chapter 1 Critical Review o f the Literature 19

particularly in the light of the empirical finding (Pope and Vetter, 1991) that harm to patients occurred in 80% of the cases in which therapists engaged in sex with a patient after termination of therapy. The decision making ability of discharged patients may continue to be compromised, either because of their presenting problems, or because of residual transference (Applebaum and Jorgenson, 1991).

It may be argued that post-termination relationships between therapists and their patients can never be equal since the therapist must always remain available for the patient to re­ enter therapy if necessary. Equally, the transference issues persist and would influence any relationship between the parties. In relation to this latter issue, it has been argued that the initial power imbalance between the therapist and the patient can never be erased (Herman et al, 1987).

Strean (1993) suggests that post-termination sexual contact involves unresolved transference and countertransference issues which are being acted out rather than discussed, particularly in view of the fact that the goal of most therapies is separation between therapist and patient, not union. Vasquez (1991) argues in a similar vein that an absolute ban upon therapist-patient sexual contact after termination of therapy would allow the client and the therapist to use therapy as effectively as possible; the client being freed to feel safe, open and trusting when the option of sexual contact is not open, and the therapist being less likely to make errors in terminating therapy.

It has been proposed that in cases where the transference has been resolved (Coleman, 1988), or after a defined "cooling off period" (Applebaum and Jorgenson, 1991) post-

Chapter Critical Review of the Literature 20 termination sexual contact may be appropriate. Coleman (1988) also proposes in cases of discharged patients that if no harm occurs to the patient as a result of sexual contact with a therapist, there should be no prohibition on this behaviour. However, of course the questions of who should determine whether the transference has been resolved, and whether harm has occurred are crucial, since clear problems would arise if this was left solely to the treating psychotherapist. There is some research to suggest that patients' thoughts of the therapist continue for some years after the termination of therapy, and that many patients consider returning to therapy in the 5-10 year period following therapy (Buckley, Karasu and Charles, 1981, cited in Shopland and VandeCreek, 1991). This would suggest that the notion of a "cooling off period” may be inappropriate, unless it were of more than 10 years' duration.

Gonsoriek and Brown (1989) propose a solution to this problem based on differentiating between types of therapy received by patients, suggesting that post-termination sexual contact should be permanently prohibited where transference played a central part in the therapeutic relationship, where therapy was long term, and where there was a clear power difference between therapist and patient. For other, short term, structured therapies, sexual contact between therapist and patient may be permissible, but only under specified conditions, such as following a two year period, and where the patient is not severely disturbed.

Rutter (1989) suggests that in his experience, most long term relationships/marriages which occur between therapists and patients (and others in similar positions) involve almost insurmountable difficulties and simply perpetuate exploitative power relations.

Chapter Critical Review o f the Literature 21 A novel perspective on this issue is provided by the research of Geller, Cooley and Hartley (1981-1982, cited in Vasquez, 1991) whose research suggests that improvement in psychotherapy patients is associated with their internal image of their therapist. Presumably, therefore, anything which interfered with this image of the therapist, would have a negative impact upon the client's progress after therapy, including, potentially, sexual contact (Vasquez, 1991).

Brown (1988) argues that female sexuality is such that the development of a sexual relationship is not, for women:

"a demarcated phenomenon defined solely by genital contact, overt arousal, and orgasm. Rather, sexuality is perceived as developing along a continuum which begins with feelings of attachment and intimacy and expands over time to include physical and genital components"

(Brown, 1988, p.251)

Thus in these terms, what is frequently referred to as a "post termination" sexual or romantic relationship between therapist and patient, where one of the parties is female, is impossible since the onset of feelings of attraction occurred within the context of the therapeutic relationship:

"the possibility that the client might become a lover has entered the process o f therapy, and contaminated it, however subtly"

Chapter 1 Critical Review of the Literature 22 Several attempts have been made to find a solution to the problem of post-discharge sexual contact between therapists and their patients, in the context of professional bodies' ethical codes. A number of professional bodies, both in the U.K. and the U.S.A., have made recent amendments to their ethical codes, to allow for sexual contact between therapist and patient after a specified period following discharge. The time period varies from twelve weeks (British Association for Counselling, cited in Jehu, 1992) to two years under certain conditions (American Psychological Association, 1992; British Psychological Society, 1996).