Confronting An Impasse
A repeated theme of this book is that there are no clear, one-size-fits-all answers to therapeutic dilemmas, complexities, and challenges. Various theoretical orientations provide different, sometimes opposing ways of approaching questions. Each therapist, each client, and each situation is unique, whatever qualities they may share with other therapists, clients, and situations.
The tenets of this book place fundamental trust in the individual therapist, adequately trained, aware of the relevant research and theory, and consulting with others, to draw his or her own conclusions. Virtually all therapists have learned primary resources for helping themselves explore problematic situations when they hit an impasse, when they are unsure what to do or even what questions to ask. Depending on the circumstances and the nature of the impasse, therapists may, for example, (a) consult, (b) re-read the available research and clinical literature, as well as search for just-published findings or discussions, (c) introspect, (d) seek supervision, and even (e) begin or resume personal therapy.
But there are times when, even after the most sustained exploration, the course is not clear. The therapist's best understanding of the situation suggests a course of action--perhaps one involving a complex dual (or multiple) relationship or other boundary issues--that seems productive yet questionable and perhaps potentially harmful. To refrain from a contemplated action may shut the door to the therapist's spontaneity, creativity, intuition, and ability to help; to refrain may stunt the patient's progress or impede recovery. However, to engage in the contemplated action may lead to disaster. It may be helpful for therapists, having reached an impasse, to examine the potential intervention in light of the following 10 considerations, the first 2 of which focus on sexual issues in light of research suggesting that sexual feelings in therapy can make most therapists feel "guilty, anxious, and confused."
A Fundamental Prohibition
Among the fundamental considerations is this: Is the contemplated action consistent with the prohibition against therapist-patient sexual involvement? Under no circumstances should a therapist ever become sexually active with a patient. No matter what the situation. No matter who the patient. No matter what the patient has said or done. No matter how the therapist or the patient feels. Therapist-patient sexual involvement is in all instances wrong and must be avoided.
In all situations, it is solely the therapist's responsibility to ensure that he or she never engages in sex with a patient. The locus of responsibility for the therapist's behavior in this regard can never be shifted; it remains always and completely with the therapist.
Consequently, when considering how to respond to sexual feelings, what course of action might be appropriate, the therapist must frankly ask, Does this possible course of action in any way involve sex with the patient? If the answer to that question is anything but a clear "no," the contemplated action must be rejected.
The Slippery Slope
The second consideration may require much more self-exploration and a deeper knowledge of oneself. Is the contemplated course of action likely to lead to or create a risk for sexual involvement with the patient? The contemplated action may not, in and of itself, constitute or even connote sexual involvement with the patient. Yet it may represent, depending on the personality, strengths, and weaknesses of the therapist, a subtle first step on a slippery slope. In most cases, only the therapist can honestly address this consideration.
Consider the following scenario:
You find yourself feeling something--you are not quite sure what--for a patient. You are aware that you feel a closeness to her, a kind of connectedness and rapport that is unusual for you. Each session, she comes in and sits on the couch. You sit in your chair. However, at the next session, she begins sitting in the chair, leaving the couch for you to sit on. After several sessions of this pattern--she coming in and sitting on the chair, you then taking a seat on the couch--she announces, in the middle of a session, that she doesn't like being so far away from you, so she comes over and sits on the other end of the couch.
What do you do?
Obviously, therapist and patient sitting at far ends of a long couch does not constitute sexual involvement. Nor does she give any indication that she wants to be any closer to you.
Depending on their theoretical orientation, their personal style, the specific therapeutic relationship, the needs of the patient in the scenario, and other factors, many therapists would probably make some comment about this new seating pattern.
But what would you do during the rest of the session and during future sessions?
It is our belief that there is no one-size-fits-all answer that uniformly applies across all theoretical orientations, situations, and so on. But if such factors would allow this "closer" seating arrangement, the therapist needs to consider what it means and where it may lead. In some cases, it might reflect a tacit agreement between therapist and patient to move physically closer. Some therapists in some versions of this scenario might recognize that incremental movements toward increased physical closeness, if continued, might set the stage for sexual intimacies. No specific movement, in and of itself, would seem particularly remarkable, risky, or inappropriate. Each would have ample justification (or rationalization). The lack of a drastic or sudden action could allow physical closeness to increase gradually until therapist and patient achieved a physical intimacy that was subtly or clearly sexual.
When in the midst of such situations and unsure how to proceed, each therapist must carefully consider actions that may lead, by small, seemingly insignificant-in-themselves increments, toward sexual involvement with a client. Those who wonder if they are progressing down this slippery slope may find it useful to complete the structured self-evaluation suggested by Pope and Bouhoutsos in their book Sexual Intimacies Between Therapists and Patients (1986; see also Pope, 1994).
Consistency of Communication
The third consideration invites the therapist to review the course of therapy from the start to the present: Has the therapist clearly and consistently communicated to the patient about the nature of and evolution of this venture? Has the therapist mislead or deceived the patient in any way? Can the patient trust what the therapist explicitly says as well as implies? Whatever the rationale might be, is the therapist lying to the patient, and if so, what are the reasons and consequences? In some instances, a therapeutic impasse or dilemma may result from something that has not been acknowledged or discussed. Are there taboo topics that the therapist feels constrained not to bring up and address frankly? Reflecting on any taboo topics or outright deceptions in a therapeutic relationship sometimes helps therapists to resolve a therapeutic impasse or decide whether a specific intervention makes sense.
The fourth consideration requires the therapist to assess whether there taking the contemplated action should be deferred until some issue can be clarified with the patient. Has the patient said or done something that, upon reflection, doesn't fit with the therapist's understanding of what is going on? Are there important issues that the patient brought up and dropped that might be relevant? Repeatedly, therapists who faced an impasse or were unsure what to do have found that, when they carefully reviewed their work with the client, there was something the client said or did that, when carefully considered, didn't seem to fit or to make sense, or had been brought up by the client and then quickly dropped. Identifying this anomaly and clarifying it with the client has been helpful.
The Patient's Welfare
The fifth consideration is one of the primary touchstones of all therapy: Is the contemplated action consistent with the welfare of the patient? The therapist's feelings--especially when based in fear, anger, or sexual attraction--can be so powerful, complex, and personally immediate that they can create a context of their own. In this context, the therapist can respond to vivid personal feelings, impulses, desires, fears, and fantasies while the patient's clinical needs lose their salience.
Complex legal issues may make this consideration more difficult. In some instances, a therapist may take an action that may not be construed by all concerned as clearly consistent with the welfare of the patient. For example, a therapist may be legally required to report that the patient has engaged in child abuse or has threatened to kill a third party, even though some therapists may believe that such reports are not consistent with the welfare of the patient.
Within the context of legal and related complexities, which may seem overwhelming, it is important to consider the degree to which any contemplated action promotes, is consistent with, is irrelevant to, or is contrary to the patient's welfare. Both therapist and patient, for example, may enjoy talking at length about current events, or about specific movies they've seen, or about current events, or about the patient's sexual fantasies. But the therapist must frankly address the questions: Does such discussion serve a legitimate therapeutic purpose? Is it consistent with the patient's welfare? Does it help address the needs or questions that prompted the patient to seek therapy or that emerged during the course of therapy? Regarding the examples, there is no predetermined or universal answer that spans all therapeutic situations. In some instances, such discussion may be vital to the patient's progress. In others, it may be extremely destructive. Nothing can spare therapists from struggling with such questions each time they arise.
The sixth consideration is another primary touchstone of therapy: Is the contemplated action consistent with the basic informed consent of the patient? Consent is one of the most difficult issues with which therapists must contend (see, e.g., Ethics in Psychotherapy and Counseling, 2nd edition). Legal requirements for informed consent to treatment and informed refusal of treatment vary according to jurisdiction. There are often instances in which patients are subjected to interventions that are contrary to their voluntary consent. For example, a person who is actively suicidal, homicidal, or gravely disabled may, again depending on applicable law for the jurisdiction, be involuntarily hospitalized. However, patients are generally accorded rights to informed consent or informed refusal. Each act or set of actions by a therapist must be carefully considered in light of its consistency with the person's autonomy and his or her right to choose what forms of treatment to try or to avoid.
Adopting the Patient's View
The seventh consideration is one that invites the therapist to empathize imaginatively with the patient: How is the patient likely to understand and respond to the contemplated action? Therapy is one of many endeavors in which exclusive attention to theory, intention, and technique may distract from other sources of information, ideas, and guidance. Therapists-in-training may cling to theory, intention, and technique as a way of coping with the anxieties and overwhelming responsibilities of the therapeutic venture. Seasoned therapists may rely almost exclusively on theory, intention, and technique out of learned reflex, habit, and the sheer weariness that approaches burnout.
There is always risk that the therapist will fall back on repetitive and reflexive responses that verge on stereotype. One way to help avoid responses that are driven more by anxiety, fatigue, or similar factors is to consider carefully how the therapist would think, feel, and react if he or she were the patient. Regardless of the theoretical soundness, intended outcome, or technical sophistication of a contemplated intervention, how will it likely be experienced and understood by the patient? Can the therapist anticipate at all what the patient might feel and think? The therapist's attempts to try out, in his or her imagination, the contemplated action and to view it from the perspective of the patient may help prevent, correct, or at least identify possible sources of misunderstanding, miscommunication, and failures of empathy.
The eighth consideration is one of competence: Is the therapist competent to carry out the contemplated intervention? Ensuring that a therapist's education, training, and supervised experience is adequate and appropriate for his or her work is an important clinical and ethical responsibility. "The Ethical Principles of Psychologists and Code of Conduct" of the American Psychological Association (1992), for example, emphasizes that
Psychologists ... recognize the boundaries of their particular competencies and the limitations of their expertise. They provide only those services and use only those techniques for which they are qualified by education, training, or experience.... They maintain knowledge of relevant scientific and professional information related to the services they render, and they recognize the need for ongoing education. (p. 3)
As an extreme example, consider a hypothetical male therapist who discovers, in the second month of work with a patient, that the patient is the victim of child sex abuse. The patient says that he or she fears the therapist and finds it difficult to talk because sexual memories keep intruding. The therapist has listened to colleagues discuss "reenactment therapy'' and decides that this might be an appropriate intervention to try on a trial basis with this patient. He asks the patient to describe the memory, which involved anal intercourse. The therapist then suggests that he and the patient get down on the floor, fully clothed, to pantomime the action. Although the therapist has no real knowledge of "reenactment therapy,'' the approach seems to make sense to him in light of his knowledge of learning theory and behavior therapy. He believes that reenacting the traumatic memory through pantomime, in the safety and security of the therapy office, will enable the patient to become systematically desensitized to the traumatic associations. He anticipates that after one or two slow, careful reenactments, the patient will no longer generalize the learned fear (as well as other negative feelings) to the therapist.
Especially if they are knowledgeable about interventions for people who were sexually abused as children, readers will probably be able to envision some likely disastrous consequences of the therapist's contemplated actions in this scenario. Whenever therapists consider possible interventions or courses of action (e.g., emotional flooding, systematic desensitization, using touch to help induce a hypnotic trance, "emergent uncovering'' of sexual feelings, or psychodrama), it is crucial that they candidly assess the degree not only that the intervention itself is appropriate for the client and situation but also that the therapist has adequate knowledge and training.
The ninth consideration involves alertness to unusual actions: Does the contemplated action fall substantially outside the range of the therapist's usual behaviors? That the contemplated action is unusual does not suggest per se that something is wrong with it. The creative therapist will likely try creative interventions. The typical therapist--if there is such a person--will likely engage in atypical behaviors from time to time. But possible actions that seem considerably outside the therapist's general approaches probably warrant special consideration.
For most therapists, therapy is conducted in the consulting room. Some theoretical orientations, however, may not preclude the therapist from seeing a patient outside the office if there is clear clinical need and justification. For example, Stone (1982) described a woman suffering from schizophrenia who was hospitalized during a psychotic break. The woman heaped verbal abuse on her therapist, claiming that the therapist did not really care about her. Suddenly, the patient disappeared from the unit.
The therapist, upon hearing the news, got into her car and canvassed all the bars and social clubs in Greenwich Village which her patient was known to frequent. At about midnight, she found her patient and drove her back to the hospital. From that day forward, the patient grew calmer, less impulsive, and made great progress in treatment. Later, after making substantial recovery, she told her therapist that all the interpretations during the first few weeks in the hospital meant very little to her. But after the ``midnight rescue mission'' it was clear, even to her, how concerned and sincere her therapist had been from the beginning. (p. 171)
Searching for a patient outside the hospital or office is an extremely atypical event for most, if not all, therapists. When the therapist undertakes such an atypical action, is it clear that such out-of-the-office contact is warranted by the patient's clinical needs and situation? Contemplated actions that are out of the ordinary invite extremely careful evaluation.
The tenth consideration concerns secrecy: Is there a compelling reason for not discussing the contemplated action with a colleague, consultant, or supervisor? One red flag to the possibility that a course of action is inappropriate is the therapist's reluctance to disclose it to others. One question a therapist may ask about any proposed action is this: If I took this action, would I have any reluctance for all of my professional colleagues to know that I had taken it? If the answer is "yes,'' the reasons for the reluctance are worth examining. If the answer is "no,'' it is worth considering if one has adequately taken advantage of the opportunities to discuss the matter with a trusted colleague. If discussion with a colleague has not helped to clarify the issues, consultation with additional professionals, each of whom may provide different perspectives and suggestions, may be useful.
Reflecting on one's motivation for seeking consultation and one's methods of selecting potential consultants can be an important part of the consultation process. In times of temptation, often there is ample motive to seek superficial, phony, or pro forma consultation as a way to obtain approval or "permission'' for a questionable behavior. The apparent consultation is an attempt to quash or override doubts rather than to explore them. Methods for selecting potential consultants can help undermine or ensure the integrity of the consultation process. Only the least persistent therapist would be unable to find, in a moderate or large community, a consultant who would say "yes'' to virtually any proposed intervention. Survey research, for example, suggests that there is a tiny, atypical minority of therapists who even believe that sexual intimacies with clients may sometimes be therapeutic (see appendix C).
Making use of consultation as a regular component of clinical activities rather than as a resource used only on atypical occasions is one way to extend the learning process beyond the time span of the specific course or study group in which this book has served as a focus of exploration and discovery. Consultation with a variety of colleagues on a frequent basis can strengthen the sense of community in which therapists work. It can provide a safety net, helping therapists to ensure that their work does not fall into needless errors, unintentional malpractice, or harmful actions that are due to lack of knowledge, guidance, perspective, challenge, or support. It can create a sense of cooperative venture in which the process of professional development, exploration, and discovery continue.
NOTE: For additional online articles discussing dual (or multiple) relationships and similar boundary issues, please see:
- Dual Relationships: Trends, Stats, and Resources
- Dual Relationships Between Therapist and Client: A National Study of Psychologists, Psychiatrists, and Social Workers
- Avoiding Exploitive Dual Relationships: A Decision-Making Model
- Ethical Decision-Making and Dual Relationships
- Ethics of Practice: The Beliefs and Behaviors of Psychologists As Therapists [American Psychologist]
- Ethics of Teaching: Beliefs and Behaviors of Psychologists As Educators [American Psychologist]
- Ethical Dilemmas Encountered by Members of the American Psychological Association [American Psychologist]