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Chapter: Essentials of Psychiatry: Professional Ethics and Boundaries


Abstinence means that psychiatrists should discourage direct forms of pleasure such as touching or sexuality in the course of their interactions with patients.



Abstinence means that psychiatrists should discourage direct forms of pleasure such as touching or sexuality in the course of their interactions with patients. In the therapeutic relationship, the patient’s ability to consent to sexual activity with the psychiatrist is vitiated by the knowledge the latter possesses over the patient and by the power differential that vests the psychiatrist with spe-cial authority.


For patients, actual gratification from the psychiatrist is best confined to realistic goals for recovery and emotional growth. Psychiatrists should limit themselves to the pleasure of getting paid for a job well done and for the opportunity to par-ticipate in an interesting and creative profession. Although stead-fast application of this boundary can be quite frustrating for both doctor and patient, it pays excellent dividends in the long run by encouraging autonomy and a more mature way of dealing with impulses. The rule of abstinence as a therapeutic boundary has an analogous function to the incest taboo as a social organizer. In all known human cultures, the incest taboo has survival value be-cause, during childhood development, it serves to strengthen the sense of individuality and personal boundaries so necessary for growth, independence and social responsibility (Parker, 1976).


From a practical standpoint, psychiatrists can strengthen their patients’ boundaries in this regard by resisting behaviors such as physical touching, accepting gifts, socialization outside treatment and sexual involvement. The patient receives the fol-lowing messages from a clinician who is able properly to adhere to this principle:


The doctor is more interested in my health than his/her own gratification and doesn’t try to take possession of me. I am learning that I can have wishes that needn’t result in action.


There are occasions when psychiatrists are obligated to employ physical procedures such as taking blood pressures, checking for extrapyramidal symptoms, restraining dangerous patients, or administering electroconvulsive therapy. Indeed, clinical touching of patients is considered an integral part of the physician–patient relationship because of its important role in physical examination and therapeutic procedures. Even though psychiatrists are physicians, they are obligated to use much more restraint in this regard than is expected of colleagues in other branches of medicine. It is probably too invasive for the same physician, on a protracted basis, simultaneously to intrude both into the patient’s psychological and physical spaces.


Other risky forms of gratification include embracing or kissing patients, eating and drinking with patients, socializing with patients outside of the therapy setting, and failure to under-stand and resolve recurrent or obsessive sexual fantasies about a patient. Engaging in sexual behavior with current or former pa-tients is contraindicated because it is almost invariably destruc-tive, even though the damage may not be immediately manifest.


The APA (American Psychiatric Association, 1993) took a principled and unequivocal stand regarding sexual activity be-tween psychiatrists and their current or former patients:


Additionally, the inherent inequality in the doctor–patient rela-tionship may lead to exploitation of the patient. Sexual activity with a current or former patient is unethical.


The APA’s position is in agreement with the principles es-poused in the Hippocratic Oath, which clearly mandates that a physician approach a patient “for the benefit of the sick, and… abstain from every voluntary act of mischief and corruption; and, further, from the seduction of females or males, of freemen and slaves”.


Despite the ancient basis of this proscription and convincing evidence in our times of the damaging effects of sexual relation-ships between therapists and former patients (Epstein, 1994, pp. 218–220; Luepker, 1990; Brown et al., 1992), some authors have raised legal and theoretical challenges to the permanent prohibi-tion contained in the APA guidelines (Appelbaum and Jorgenson, 1991). While refraining from calling for a repeal of APA’s ethical proscription against sex with former patients, Malmquist and Notman (2001) argued that legal misapplications of imprecise and unproven concepts of transference and countertransference have exposed therapists who enter post termination sexual liaisons with their patients to inappropriate legal liability.


Research examining the causation and prevention of human error have provided neurocognitive evidence supporting the ancient wisdom of Hippocrates’ injunction. Skilled perform-ance is subject to potentially calamitous error when experts fail to follow empirically derived safety guidelines or lack an adequate knowledge base upon which to initiate critical interventions (Reason, 1990, pp. 76, 84, 86, 146–147). Skillful performance in conducting medical procedures are acquired from overlearned behavior that enables an expert to undertake complex cogni-tive and behavioral operations in a smooth and rapid fashion. Performance skills in which success depends on overlearned and automatic processes rely primarily on the procedural memory system (Cabeza and Nyberg, 2000). The Hippocratic mandate of approaching the patient solely for their benefit and to avoid mis-chief is a prime example of an overlearned, automatically embed-ded, error protection message acquired through years of medical training. Anything that interferes with such an intensively elabo-rated internal safeguard endangers patients’ well-being.


Whether they realize it or not, psychiatrists who justify the permissibility of post termination sexual relationships are sabotaging their own overlearned commitment to act primarily in their patient’s best interest and are exposing their patient to a biased and error prone treatment. This self-permissive attitude would make a psychiatrist more prone to engage in seductive grooming of a patient during the treatment process in anticipation of termination. In addition, biased by this attitude, a psychiatrist is likely to avoid making any communication to the patient that would discourage a subsequent romantic post termination liaison (Epstein, 2002). While a psychiatrist might consciously deny that this attitude is a violation of the Hippocratic dictum, in actual cases where psychiatrists have engaged in post termination sex with patients, their pretermination subliminal thinking ran like this:


I’m treating this patient only for her/(his) benefit. Like Hippocrates, I will abstain from every voluntary act of mischief and corruption and, further, from seduction. However, after I cure this very attractive patient, I will keep his/(her) phone number, and after a respectable period of time, it will be a dif-ferent matter, and we will see what will happen.



Note that this reasoning represents a form of dissociative thinking based on a primitive wish for inappropriate gratification with a patient that magically disavows the connection between post treatment behavior and pretreatment reality. All psychiatric treatment is based on the assumption that a psychiatrist’s inter-ventions by means of positive attitudes, words, deeds and medical interventions will have a lasting beneficial effect on the patient after the treatment has ended. There is no realistic escape from the fact that the reverse is also true, namely, that inappropriate attitudes, words, deeds and interventions are likely to have a last-ing harmful effect on the patient after the treatment has ended.

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