Confidentiality in Therapy
The psychiatrist in the clinical vignette fails to maintain confidentiality. To gain the patient's confidence, he shares intimate informa-tion about other patients. This creates the illusion that she is special.
The maintenance of confidentiality is an absolute boundary guideline that must be followed unless specific clinical, ethical, or legal exceptions arise.13 Con-fidentiality must be maintained unless release of information is competently authorized by the patient. Breaches of confidentiality typically occur when therapists are in double agent roles.I6 Such roles occur when the therapist must serve simultaneously the patient and a third party. For example, prison and military mental health professionals frequently find themselves in double agent roles. Clinicians working in man-aged care settings frequently find them-selves also struggling with dual roles.
Informed Consent Although the law requires informed consent for treat-ments and procedures, informing pa-tients of the risks and benefits of a pro-posed treatment incidently, but impor-tantly, maintains patient autonomy and fosters the therapeutic alliance.26 In a number of sexual misconduct cases, drugs and even ECT have been used to gain control over patients.27 Boundary violations concerning medication prac-tices are particularly egregious in these cases. Obviously, no effort is made to inform the patients of the risks and ben-efits of prescribed medication. Fre-quently, large amounts of addictive medications are given, particularly bar-biturates and benzodiazapines.
In an effort to gain control over the patient, the psychiatrist in the vignette negligently plies her with increasing amounts of barbiturates and alcohol. If the addictive risks of barbiturates had been explained to the patient, her earlier history of narcotic addiction might have been revealed. The psychiatrist, how-ever, is perusing a personal rather than a clinical agenda. Thus, the patient's need for autonomy and self-determina-tion is subjugated to the therapist's de-sire to make the patient dependent upon him.
The process of psychotherapy requires that the interac-tion between therapist and patient be basically verbal. Engaging the patient verbally tends to check acting out re-sponses by the therapist. In psychother-apy, the therapist must always be alert to the possibility of acting out his or her emotional conflicts with the patient. This can manifest itself either through the therapist's behavior or by inducing the patient to act out.
There is, however, a fundamental dif-ference between active interventions un-dertaken by the therapist and therapist acting out. For example, when somatic therapies or behavioral modification techniques are used, active interventions are made in the service of the treatment, not for the purpose of exploiting the patient. Moreover, therapists frequently find it necessary to actively clinically intervene on behalf of patients in crisis. All therapies, even Rogerian therapy and psychoanalysis, employ active interventions and reinforcement
The danger to patients and their therapy does not arise from therapists' activity per se, but from therapists' acting out. B i b ~ - i n gpointed~~ out that all dynamic psychotherapies variously utilize catharsis, suggestion, anipulation, clarification, and insight in their therapeutic approaches to the patient. Regardless of the methods favored, the patient should be primarily engaged on a verbal rather than on an action level. Although it is certainly possible for therapists to act out exclusively on a verbal level, the behavioral expressions conflict by therapists are much more common and damaging to patients. For example, in the clinical vignette, the psychiatrist induces the patient to engage in a host of acting out behaviors including a sexual relationship.
Therapist client relationship
The boundary violations in the hypothetical vignette are, unfortunately, all too common in reality. Even if sex did not take place, the psychiatrist abandons a neutral position and damages the patient. The progressive precursor boundary violations prevented appropriate diagnosis and treatment of the patient's depression, inducing a barbiturate addiction and exacerbating a preexisting Borderline Personality Disorder.
Most therapists accept the boundary guideline principle of no previous, current, or future personal relations with the patient. For a number of sound clinical reasons, post-termination relationships with patients should be avoided.
Past and current personal relationships with a patient hopelessly muddles treatment boundaries and dooms any therapeutic efforts. The social chit chat that usually ensues is not psychotherapy. Transferences are often timeless, raising serious concerns about a former patient's ability for autonomous consent to a post-termination relationship.
Long hugs in psychotherapy
The essential avoidance of physical contact with patients remains a controversial issue." Occasions may arise in treatment when a handshake or a hug is an appropriate human response. Clinically correct touching often occurs in the course of administering a procedure or treatment. Therapists who work with children, the elderly, and the physically ill frequently touch their patients in an appropriate, clinically supportive manner. An absolute prohibition against touching the patient would preclude such therapeutic human responses and supportive clinical interventions. Obviously, the psychiatrist in the vignette violates the guidelines against a personal relationship with the patient and the essential avoidance of physical contact. Therapists must be extremely wary of touching patients. Hugging may seem innocuous, but when closely considered, most hugs contain erotic messages. The practice of gratuitously touching the patient is often clinically inappropriate and may be a prelude to sexual i n t i m a c i e ~ .
Holroyd and rods sky^' found that nonerotic hugging, kissing, and touching of opposite sex patients but not same sex patients is a sex-biased therapy practice at high risk for leading to sexual intercourse with patients. Every patient has the right to maintain the integrity and privacy of his or her own body.
Some psychiatrists still perform their own physical examinations of patients. The transference and countertransference complications associated with physically examining psychiatric patients are well known. It is very important that a physical examination not become the first step to progressive physical involvement with the patient. The issue of sex with a terminated patient is a more complicated matter.
The proposal advanced by Appelbaum and J o r g e n ~ o nof~ ~aone-year waiting periodafter termination that "shouldminimizeproblems andallowformer patients and therapists to enter into intimate relationships" will likely disrupt treatmentboundariesfrom the outset. What deviations in treatment boundaries will occur if, during the course of therapy, the patient is considered to be a potential sexual partner after termination? Will the therapy turn into a tryst and become a courtship? Will the course of therapy be prematurely shortened so as to get to the sexual relationship? For the sake of the patient's treatment, should not the patient be irrevocably and unequivocally renounced as a sexual partner for the therapist from the very beginning? Sufice it to say that the most credible clinical position for a therapist is to stay out of the patient's life after treatment ends. The patient should be allowed to go forward with his or her life, unencumbered by the therapist and the inevitable psychological baggage carried over from treatment.
Anonymity in psychotherapy
In the vignette, the relative anonymity of the therapist is not maintained. The patient is burdened by the problems of the therapist, wasting valuable treatment time that the patient needs for her own care.
Therapist self-disclosure is also a complex Self-disclosures that demonstrate the therapist's struggle with the problems of being human can be very supportive to some patients. Patient and therapist shared regression is one of the obvious dangers of therapist self-disclosure. Although some therapists have found that sharing a personal experience may prove helpful to a patient, the self-disclosure of current conflicts and crises in the therapist's life may create a role reversion in the patient who then attempts to rescue the therapist. Even if role reversion does not occur, therapist self-disclosures in themselves may unnecessarily emotionally burden the patient. Details of the therapist's personal life, particularly sexual fantasies and dreams should not be shared with patient^.^' Therapist self-disclosures appear to be highly correlated with the development of therapist-patient sex. On the other hand, clinically appropriate self-disclosure may be necessary if the therapist is suffering from an illness that might negatively impact upon the treatment or may cause the therapist to be absent from therapy for a long period of time.
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