The subject of sexual relations between therapist and patient has saturated the media of late. Last November My Doctor, My Lover appeared on public television's Frontline, bringing the intimate perspectives of both therapist and patient into the living rooms of millions of viewers. Shortly thereafter Barbra Streisand's Prince of Tides depicted a torrid love affair between an unhappy female psychiatrist and the brother of one of her patients. Audiences left the theater comforted in the knowledge that a therapist's love—not her technical expertise—is the decisive factor in her capacity to help patients overcome traumas from the past.
The new year brought yet another analyst-in-love-with-a-patient's-sibling to the screen with the arrival of Final Analysis. This time the analyst was played by Richard Gere (cast for his resemblance to the analysts we all know), and the sibling is played by the ravishing Kim Bassinger. The screenwriter demonstrates his concern about ethical transgressions, however, by including a scene in which the Richard Gere character talks to a colleague about what he has done. Citing the AMA code of ethics, he assures his colleague that there is no prohibition against sex with a patient's sibling!
Fortunately, Final Analysis died at the box office. Of far greater concern was the subsequent resignation of the deputy medical director of the American Psychiatric Association after acknowledging sexual transgressions with a patient. On the heels of this disclosure came a veritable feeding frenzy in the media surrounding the Boston case of a female therapist who allegedly had sexual relations with a male patient. The media circus that has ensued has given potential patients throughout the country cause to think twice about seeking psychotherapy or psychoanalysis.
This media blitz on the topic of therapist-patient sex may obscure the fact that legitimate scientific issues calling for rational discourse have been raised. In the November 1991 issue of the American Journal of Psychiatry, Paul Appelbaum and Linda Jorgenson wrote a lead article entitled “Psychotherapist-Patient Sexual Contact After Termination of Treatment: An Analysis and a Proposal.” The authors, a respected forensic psychiatrist and a well-known plaintiff's attorney in the field, argue that the current American Psychiatric Association ethical code, which states that post-termination sex “almost always is unethical,” has not served the profession well. They suggest that a more reasonable solution is to impose a one-year ban on post-termination sex. This waiting period, in their view, would be sufficient to prevent impulsive terminations of treatment designed to allow therapist and patient to begin a sexual relationship. Patient and therapist alike would have the opportunity to consider their mutual attraction contemplatively, with no regular ongoing contact. While acknowledging that transference continues beyond termination, the authors state that clinical experience suggests a diminution in intensity after therapist and patient are separated for a time.
To the authors' credit, they realize that the choice of the patient as an object of romantic and sexual involvement is likely to be problematic. Their perspective, however, is utilitarian. Recognizing that such involvements have always occurred and most likely will continue to, they have sought to think about the problem from the standpoint of “what policies might be most consonant with the usual approach of our society to consensual sexual relations and yet responsive to legitimate concerns about harm and unfairness to former patients” (p. 1472).
I strongly disagree with the conclusions reached by Appelbaum and Jorgenson, and I believe the field of psychoanalysis has much to contribute to this controversy.
If therapist-patient sex is unethical and likely to be damaging during the course of treatment, the same concerns should apply following termination. By far the most sensible policy for psychoanalysts and psychotherapists is “once a patient, always a patient.” The persistence of transference following termination is dismissed too glibly by Appelbaum and Jorgenson. Both the clinical and the research literature reveal a broad consensus that transference is strikingly persistent.
Pfeffer's 1963 follow-up study of patients after termination found that even well-analyzed patients spontaneously revive the transference paradigms typical of their analyses. “After the analysis,” he concluded, “the patient retains an important and complicated intrapsychic representation of the analyst” (p. 230). This finding has been substantiated so widely that it is now commonly known in New York as the “Pfeffer phenomenon.”
Norman el al. (1976) reported follow-up studies that accrued data from two or more years after termination. In analyses regarded as successful by both analyst and patient, the researchers found that the transference neurosis persisted as a latent structure in the patient's intrapsychic world. In studying patient dreams after termination of psychotherapy, Carlson (1986) observed that post-treatment consolidation of the psychotherapy experience involved a good deal of transference phenomena. Oremland et al. (1975) noted that terminated patients internalize an unanalyzed idea of the analyst that they carry with them after termination and relate to as an important introject. These studies indicate that the same transference issues would be instantly reestablished, even after a year of separation, were therapist and patient reconnected. The same reasons for holding sexual relations ill-advised during the course of treatment apply with equal strength once contact is reestablished.
In addition to the phenomenon of residual transference following termination, many cases indicate that transference actually intensifies after termination. Novey (1991) has described a male patient who returned to see his female analyst following termination and experienced intense erotic feelings toward her. She made the point that the transference neurosis did not peak until a full two years after termination. In a study of 97 psychotherapists who had themselves completed personal psychotherapy or psychoanalysis, Buckley et al. (1981) observed a gradual working-through process of unresolved transference long after termination. Indeed, they viewed it as an important determinant of successful treatment. All of their subjects had considered returning to analysis or therapy during the 5-to 10-year period following termination, and thoughts about the therapist reached a peak during this same time frame. As we all know, the unconscious is timeless. The intrapsychic attachment to forbidden
Glen O. Gabbard, Training and Supervising Analyst, Topeka Institute for Psychoanalysis. Vice President for Adult Services, The Menninger Clinic
objects, whether parents or analysts, knows no time limits.
One of the strongest arguments against removing the prohibition of post-termination sex is the profound impact such a shift would have on the psychotherapy process. The very essence of psychoanalytically oriented treatment is that the patient must give up long-held yearnings for incestuous objects. A mourning process must occur whereby patients realize that they can never have the opposite-sex parent for themselves. These longings are reactivated in the transference and must be worked through with the therapist or analyst. The termination phase is particularly problematic in this respect. Most patients do not want to accept the finality of termination, and many therapists and analysts have parallel problems in that phase of the therapy, preferring to avoid feelings of grief and mourning through the use of denial.
A number of cases of therapist-patient sex that have come to my attention have been initiated as a defense against the necessary work of termination. As a hypomanic defense against impending loss, therapist and patient collude in the fantasy that a new relationship is beginning rather than an old one ending. Lifting the ban on post-termination sexual relations would simply reinforce this resistance to facing the finality of termination. Both therapist and patient could exploit the loophole of a one-year waiting period to bypass the mourning process. Patients engaged in termination could cling to the hope that some day their longings for the therapist will be gratified.
Calef and Weinshel (1983) reported that patients commonly terminate with a feeling of “unfinished business.” This feeling often relates to the patient's sexual wishes to consummate the relationship with the analyst at some future date. The authors noted that such longings may be present in patients who otherwise are well analyzed and may persist for many years after termination. The adoption of a more lenient ethical code may lead patients to regard them not as fantasies to be analyzed but rather as realistic longings to be gratified.
Resistances to self-disclosure in psychotherapy and psychoanalysis would also be heightened if the possibility of a sexual relationship with the therapist became real for the patient. Patients might conceal shameful or embarrassing material lest they make themselves appear less sexually desirable, and sexual difficulties might be censored from one's associations. Were a one-year waiting period to become the ethical standard, patients and therapists might rush to premature termination so that they might begin counting the days sooner. Therapists in the throes of erotic countertransference might be at pains not to upset the patient by bringing up unpleasant issues, because an idealizing transference might be advantageous after termination.
Beyond the issues of persisting transference and the harmful impact on the psychotherapy process, there are practical reasons to maintain a policy of “once a patient, always a patient.” Formal ethical standards, legislation, and case law recognize that the professional relationship does not end with the discontinuance of therapy. Therapists are obligated to respond appropriately to their patients' rights to privacy, confidentiality, and privilege (three separate though interrelated concepts), and this obligation is unaffected by termination or the subsequent passage of time.
Similarly, most states have passed legislation requiring therapists to maintain records beyond the date of termination. When served a valid subpoena, therapists cannot refuse to offer expert testimony concerning their patient simply because sessions have terminated.
Nor do these legal arguments exhaust the matter. The assumption of professional responsibility for terminated patients is also clinically practical. Psychoanalysts and psychotherapists are often contacted by patients who wish to return for a few consultations or reanalysis. In a recent study of 71 successfully analyzed patients (Hartlaub et al. 1986), two-thirds had contacted their analysts within three years of termination. These patients did not return because their analyses were incomplete or ineffective. On the contrary, they were doing rather well but required recontact to solidify gains they had made. Some needed to work on continued deidealization of the analyst, while others needed assistance in reactivating their self-analytic function. Still others felt the need to report developmentally important accomplishments and thereby continue the process of restructuring internal self and object representations, a process often referred to as receiving “new paint on old introjects.”
Organized psychoanalysis has not been particularly vocal in the controversy regarding post-termination sexual involvement. While I believe that the majority of analysts would agree with my position, a lack of clarity on the matter is historically evident. The history of psychoanalysis is replete with examples of analysts who have become sexually involved with or even married former patients. Even today most of us know of colleagues who have married former patients, sometimes with disastrous results, though in other cases with outcomes which apparently are mutually satisfactory.
Regardless of the few cases that seem to involve no exploitation or harm, the preponderance of evidence is that in the vast majority of cases therapist-patient sexual involvement leads to considerable harm (Williams, 1992). In developing policy, ethical codes must be established based on the rule rather than the exception. Consider an analogy: While it is possible that certain individuals might be able to drink a quart of hard liquor and drive home from a bar without getting involved in an accident, the majority of drivers cannot expect such a favorable outcome. Hence, the laws against driving while intoxicated are geared to the majority of motorists with standard physiological responses to alcohol.
Finally, the argument by Appelbaum and Jorgenson that therapist-patient sex is going to occur regardless of ethical sanctions or criminal penalties does not justify sanctioning it as acceptable after a one-year period. As a profession, we should be able to recognize that something is amiss when a therapist develops an all-consuming infatuation for a patient. Considering the fact that many other people are available, the exclusive preoccupation with someone ethically forbidden should prompt the therapist to engage in a self-analytic process, at the very least, or to seek consultation with a colleague.
Our literature is woefully inadequate on the subject of managing erotic and eroticized countertransference, and we could all benefit from some systematic attention to this topic. In the meantime, the policy of “once a patient, always a patient” represents the most ethical and responsible professional position.