Potential Consequences of Diagnostic Labels
Diagnoses of mental disorders carry implications that are differ-ent from diagnoses of purely somatic illnesses, in part because of the societal stigma attached to mental illness. This stigma has ancient roots. Humankind attaches great power to the mind but finds it deeply mysterious. One of the worst fears is the loss ofcontrol of meaningful communication, decision-making ability and intellectual capacity (Trad, 1991). Even accepting the medi-cal model that grants validity to the diagnosis of mental disor-ders, the psychiatrist still faces ethical tensions in making such diagnoses.
Because confidentiality is not absolute, a patient’s diag-nosis is available to many parties, with practical consequences. Opportunities to obtain employment or insurance may be con-strained by the documented presence of a psychiatric illness. Conversely, such a diagnosis may make tangible assistance and subsidies available based on the psychiatrist’s assessment of the patient’s disability. The clinician performing an evaluation is obliged to pay attention to any internal prejudices about patients’ entitlements and to perform the assessment as fairly as possible. Another realm of prejudice that can enter the diagnostic arena re-lates to cultural perceptions of behavior. Although there is abun-dant statistical validity to the diagnostic schema of the DSM-IV, its validity is based on the norms of the majority culture. Patients who are members of cultural minority groups may express dis-tress in ways that are inappropriately labeled as diagnosable psy-chopathology (Siantz, 1993).
There are abundant clinical reasons for maintaining clear and predictable boundaries in the patient’s relationship to the psy-chiatrist. Among other justifications, a clear therapeutic frame-work makes the psychotherapeutic environment one in which the patient can feel safe to disclose sensitive information without fear of punishment, and in which the care received is not dependent on the patient’s meeting the needs or earning the approval of the caregiver.
Maintaining the principles of respect, honesty and auton-omy of patients, all major organizations of medical and mental health professionals specifically condemn sexual contact between physicians or therapists and their patients, regardless of the form or intensity of the psychiatric treatment being provided. The ethi-cal background for this blanket prohibition stems from the nature of the therapeutic relationship. Although many of the features of the psychiatrist–patient relationship are the same as those that exist with any other physician, there are some specific facets of the psychiatric alliance that lend the issue particular distinction.
The patient enters the relationship in pain and is therefore vulnerable. Not infrequently, issues of unresolved feelings about sexuality, intimacy and dependence may be part of the problem brought to the psychiatrist. The psychiatrist is seen by society, and usually by the patient, as possessing education, authority and experience. Therefore, there is an imbalance of power in the re-lationship from the beginning. Because the patient has brought his or her problem to the trusted psychiatrist with the expecta-tion of assistance, courts and society have maintained that the therapeutic alliance constitutes a fiduciary relationship, wherein the psychiatrist is obliged to act scrupulously in the patient’s best interests, eschewing any personal advantage (Carr and Robinson, 1990; Strasburger et al., 1992).
This absolute prohibition, however, has not yielded ab-solute abstinence. Numerous surveys conducted from the mid-1970s through the late 1980s found that 7 to 10% of male thera-pists and 2 to 3% of female therapists admitted to erotic contact with patients (Strasburger et al., 1992). Rarely does sexual con-tact with patients occur in isolation. Rather, it usually represents the last in a series of steps eroding the professional and clinical boundaries of therapy. The earlier steps may include extending sessions beyond the usual time, scheduling a patient for an hour when no one else is in the office or clinic, meeting the patient for meals or elsewhere outside the treatment setting, and accepting invitations that place the therapist and patient in intimate social situations. Such compromises erode the structure that is neces-sary for therapy to be a healing process and pave the way for a destructive relationship. After the termination of therapy. Most maintain, that the fiduciary obligation does not end; that transfer-ence, despite the most intense and successful analysis, never dis-appears; that the therapist always maintains the power of confi-dences divulged in the treatment; and that a therapist who begins any therapy without having first excluded the possibility of any future sexual contact with the patient may be seen as lying in wait for the opportunity to exploit (Murphy, 1992). The consensus of practitioners and ethicists remains that, “Once a patient, always a patient’’.