Avoiding Runaway Ethics in Psychotherapy

Is Risk Management Threatening the Therapeutic Alliance?

Ofer Zur

Recently, I defended a therapist accused by his licensing board of unethical practice. At the administrative hearing, a psychoanalytically oriented board representative aggressively questioned him, berating him for not maintaining a neutral, anonymous therapeutic presence with his client, saying this constituted a transgression of appropriate boundaries. The therapist, said his interrogator, had, in effect, engaged in a "dual relationship" with his client and "harmed the transferential relationship." The board considered the infraction so serious that they sought to revoke the therapist's license for "breaching the therapeutic frame."

What had he done that was such an outrageous affront to therapeutic ethics and professionalism? A cognitive-behaviorist, he'd departed from strict "talk therapy," and accompanied a phobic client to a bank and a supermarket---places the patient had avoided for years. The therapist had conducted a standard cognitive-behavioral form of exposure therapy, an empirically supported intervention, and was operating fully within the professional standard of care. Not to mention that the treatment worked: the client's agoraphobia completely disappeared.

I patiently explained at the board hearing that crossing a boundary from in-office treatment to out-of-office treatment wasn't the same as engaging in a dual or secondary relationship with the client---the relationship remained therapeutic, even though the geography changed.

With a certain amount of hemming and hawing, the board dropped all charges---as they often do in such cases---but to save face, members required that the therapist take an ethics class anyway.

Fostering a Culture of Fear

At our professional meetings, in the legal columns that are now a regular feature of our journals, and at workshops and seminars, legal professionals, usually without any clinical training whatsoever, are giving their opinions about how we should practice, what we're allowed to do, and what we should never do---and scaring us to death in the process.

The most frequently uttered words coming from these sources seem to be "don't" and "never." Consider the commandments regularly issued against what these experts consider dangerously risky behaviors. "Don't touch your clients---a handshake is the outer limit!" "Minimize self-disclosure; keep your anonymity intact!" "Never venture outside the office with a client!" "Don't accept gifts from a client!" "Never socialize or share a meal with a client."

The problem with these blanket condemnations is that many of the forbidden acts may be among the most powerful therapeutic methods at our disposal. We know that touch is one of the most elementary human ways to relate, and can have a powerful reassuring and healing effect. Self-disclosure can help fearful and defensive clients connect with us, and learn from us through modeling---a proven cognitive-behavioral intervention in itself. Sometimes going to the client, rather than making the client come to us, is the only reasonable way of doing therapy: take, for example, the empirically successful home-based family therapies with juvenile offenders, or therapy with a homebound sick or elderly client. A gift may be an important way for a client to express gratitude; refusing it could be deeply offensive and shaming. Sharing a meal with an anorexic client is often part of an effective, system-based treatment plan. "Dual relationships" with clients are often unavoidable and therapeutically helpful for a therapist who works in a small town or rural setting---your children may go to the same school as your clients' children; you may belong to the same church or synagogue. Conscientious, ethical therapists know all this, but even as we necessarily engage in these "forbidden" activities in the interest of being good therapists, we may feel a shudder of apprehension that we're somehow dangerously flouting rules written in stone.

Risk Management vs. Standard of Care

This grotesque metastasis of risk management actually emerges from fatal confusions among risk management, psychoanalytic guidelines, and standard of care. Psychotherapists tend to conflate good, ethical, legal therapy with risk-free therapy, which protects practitioners, not clients. Again, there's nothing wrong with attending to professional risks and hazards for our own protection. That's why therapists should keep good records, establish well-articulated treatment plans, and consult clinical, ethical, and legal experts when in doubt. But watching out, primarily, for our own skins isn't the same as fulfilling our obligations to our clients.

What are those obligations? The standard of care that guides psychotherapists is a fluid mix of law, licensing regulations, ethical codes, professional consensus, community norms, and the like. We're required by law, ethics, and good clinical practice not to harm or exploit clients (which includes sexual and financial exploitation), to treat them with respect and dignity, and to protect their privacy and autonomy. We're legally and ethically bound to minimize the risk that mentally ill clients will hurt themselves or others.

Finally, when therapists confine themselves to strict risk-management behavior, they also risk blunting their own creativity, spontaneity, and sensitivity to their clients' best interests. It can be hard even to establish a therapeutic alliance with a client if you're too frightened of what might happen to allow yourself some flexibility.

Life, as every therapist knows, is often messy. Therapy can be messy, too; every day, we run into complex and ambiguous situations not covered in psychology books, much less by the professional guidelines of our profession. Lawyers and insurance functionaries are often paid to simplify life's complexities, control everything that happens, and make the messes disappear. But that isn't our job. We're here to help our clients accept, deal with, and perhaps do something creative with the messes life inevitably hands them.

This blog is excerpted from “The Ethical Eye."Read the full article here. >>

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Topic: Aging | Children/Adolescents | Ethics

Tags: ethical issues | agoraphobia | anorexic | boundaries | ED | ethical therapist | exposure therapy | family | family therapies | good therapists | HEAL | phobia | psychology | psychotherapist | psychotherapists | relationships | self-disclosure | sex | SPECT | success | TED | therapeutic ethics | therapist | therapists | therapy

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1 Comment

Friday, February 27, 2015 10:03:52 PM | posted by Maelisa Hall
Excellent points- I know that times when I have thought outside the box of traditional talk therapy in an office have come some of my client's greatest insights and progress. May we continue to grow in a profession that allows for flexibility while staying in touch with our peers so we remain grounded in our ethical principles.