The Ethical Eye Don't let "risk management" undermine your professional approach
by 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. I stated that staying in the office, regardless of the presenting problem, may seem like the only correct methodology to psychoanalysts, risk-management consultants, and many attorneys, but it may not actually help people who suffer from agoraphobia or social phobia. These clients need a therapist who's willing to leave the sanctity of the consulting room and accompany them as they practice mixing with crowds in public spaces. Finally, I tactfully suggested that transference is a strictly psychoanalytic construct, neither applicable nor useful in cognitive-behavioral therapy--an entirely different but just as legitimate approach.
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.
In another case, I defended a deaf therapist who worked with a deaf client with whom she'd socialized at a social club for deaf people. The charge, of course, was boundary violation and dual relationship. But as I successfully argued to the board, what other choice did the client or therapist have? Therapists who know sign language don't grow on trees. Furthermore, a boundary crossing--being a part of the same deaf community as the client--isn't the same as a boundary violation. Would it have yielded a higher level of care to hire an interpreter to sit in on sessions with a therapist who couldn't sign, but was a perfectly anonymous stranger to the client?
I've also testified on behalf of therapists accused of having sexual relationships with their clients. The basis of the accusations? The therapists had been asked about their sexual orientation by gay clients and had answered the question honestly before the first appointment. Such a conversation doesn't suggest a burgeoning sexual relationship, I found myself explaining, but rather fact-finding on the part of a client who's trying to protect him- or herself in a deeply homophobic culture, and a therapist's recognition of that need for self-protection.
Fostering a Culture of Fear
Welcome to the wonderful world of "risk management." Even though cases like these are quite rare, the fact that they can and do happen, and are often based on anachronistic and rigidly legalistic rules, strikes dread into the heart of most therapists. The therapists above were certainly not acting unethically or unprofessionally--quite the opposite--but they were arguably failing to follow what the malpractice insurance industry considers good strategies of risk management, or "healthy defensiveness," as some attorneys call them. …