The Ethical Eye

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. I stated that…