The Importance of Maintaining Sexual Boundaries with Ex-Clients: A Review and Commentary*Donald W. Stewart
University of Manitoba
Paula C. Battle
Private Practice, Winnipeg, MB
*An earlier version of this article was published in Guidance & Counselling, 1999, 14 (3), 37-39.
Address correspondence to: Dr. D. Stewart, Counselling Service, 474 University Centre, University of Manitoba, Winnipeg MB R3T 2N2 (204) 474-8592 E-mail: don_stewart@umanitoba.ca
Abstract
The importance of maintaining sexual boundaries in a therapeutic relationship is enshrined in the ethical codes of all mental health professions. Less is said about post-termination sexual relationships, however, and what is said focuses largely on the possible harmful consequences to the ex-client should his or her former therapist decide such a relationship should be pursued. While this is a critical issue, we emphasize the need to limit post-termination sexual relationships because of the potential harmful consequences for current and prospective clients should their therapist see any possibility of establishing a post-termination sexual relationship with them. The positions of CPA and APA on this issue are presented, along with critical commentary and considerations for practice.
The Importance of Maintaining Sexual Boundaries with Ex-Clients: A Review and Commentary
Maintaining sexual boundaries with clients should not be a particularly thorny issue. There is an abundance of evidence available in ethics texts (e.g., Keith-Spiegel & Koocher, 1985) and accumulated professional experience (e.g., Gabbard, 1994; Smith & Fitzpatrick, 1995) of the harm or potential harm to clients caused by violations of sexual boundaries. Why, then, should there be dissension within the professional community over the propriety of sexual relationships with former clients? Our goal is to explore this issue by briefly reviewing inconsistencies between the proposed revisions of the CPA and APA ethical codes and the implications of sex with former clients for our work with current or prospective clients.
The CPA and APA ethical codes
The Canadian Psychological Association's Code of Ethics for Psychologists (1991) states that psychologists should be acutely aware of the power relationship in therapy and, therefore, not encourage or engage in sexual intimacy with clients during therapy or for that period of time following therapy during which the power relationship could reasonably be expected to influence the client's personal decision-making. The companion Practice Guidelines for Providers of Psychological Services (CPA, 1989) similarly state that sexual relationships with clients are prohibited because they constitute a particular type of dual relationship that could impair professional judgment or increase the risk of client exploitation.
The proposed revisions to the CPA code (CPA, 2000) offer some minor enhancements but do not include any substantial departures from the earlier position. The revised code proposal reiterates the original code's wording about minimizing harm and avoiding conflict of interest by prohibiting sexual relationships with clients. It also contains a new point extending these concerns to students or trainees with whom the psychologist has an evaluative or other relationship of direct authority. A second minor change recognizes the inappropriateness of encouraging sexual intimacies with students or research participants, presumably to ensure these individuals have the same level of protection from sexual exploitation as do therapy clients.
Despite these enhancements, we are concerned about the revised code proposal because it continues to leave open the possibility that sexual relationships with former clients may be seen as acceptable under some circumstances. As we elaborate later, there may be some unintended deleterious effects for psychologists, clients, the public, and the profession as a whole from such a permissive stance.
Historically, the American Psychological Association has also prohibited sexual activity with current clients, but has allowed sex with former clients if certain conditions could be met. In its Ethical Principles and Code of Conduct (1992), APA provided detailed guidelines about how and when sexual relationships with former clients may be permissible. It stated that psychologists were not to engage in sexual intimacies with a former client for at least two years following termination of professional services, and even following the two-year interval, psychologists interested in pursuing such a relationship bore the burden of demonstrating that there had been no exploitation of the client arising from the development of a post-termination sexual relationship.
In the proposed revision to its Ethical Principles and Code of Conduct, APA has sought to change its position on this issue and is considering a ban on post-termination sexual relationships with clients. In an APA Monitor article (Martin, 1999), it was announced that APA's Ethics Code Task Force is proposing a "perpetuity rule" that would prohibit sexual relationships with former clients regardless of how much time had elapsed since their last visit. According to Martin, the draft of the proposed standard simply states that "psychologists do not engage in sexual intimacies with their former therapy patients or clients."
Martin (1999) notes several reasons why the APA standard has been strengthened in the proposed revision, including (a) increased clarity in addressing the inherent power imbalance in therapy, (b) recognition that this imbalance is not erased with termination, (c) possible harm that could arise from a likely waiver of privilege and confidentiality should a post-termination complaint arise, (d) concern that a time-limited ban could interfere with ongoing therapy or resumption of therapy following termination, and (e) awareness that the American Psychiatric Association's total prohibition on post-termination sexual relationships, shared by the Canadian Psychiatric Association (Blackshaw & Patterson, 1992; Mellor, 1980), might lead the public to feel that psychiatrists place a higher value on protecting clients' interests and well-being than do psychologists.
Our position is generally consistent with the APA proposal that there are many good reasons to prohibit post-termination sexual relationships. What we are particularly concerned about is how any possibility of post-termination sexual relationships may deleteriously affect ongoing therapeutic relationships as well as the future professional functioning of some psychologists (cf. Martin, 1999).
The possibility of clients as future sexual partners
If the public is to be well-served, the recipients of professional psychological services must be able to trust that their best interests are the sole motivating factor in their therapists' interactions with them. Most psychologists would support this position, and would not advocate anything that could act to erode public confidence in their profession or deter the public's use of needed services (cf. APA. 1992).
By allowing for the possibility of post-termination sexual relationships, however, our profession may be sending mixed messages both to the public and to our members. On one hand, we hold our ethics code as sacrosanct, but on the other hand we tolerate enough vagueness and subjectivity in wording to allow possible violations of one of the cardinal rules of psychological practice.
To put it simply, if there is any possibility that the person sitting across from them in their office may become a sexual partner at some point, is there not a corresponding possibility that psychologists' perceptions, judgment, and 'behaviour may be altered in ways that do not work to the client's benefit? Moreover, even if the risk of this is small, are the possible consequences of this not so undesirable that they outweigh any of the possible "benefits" to the client of having sex with their ex-therapist?
Our concern in posing these questions is that the possibility of post-termination sexual relationships may lead to a variety of subtle shifts in practice, such as longer or more frequent sessions, increased self-disclosure, unnecessary discussion of sexual or relationship issues not central to the client's presenting problems, or other effects acting to stretch the boundaries of the therapeutic relationship (cf. Epstein & Simon, 1990).
In each of these examples, it is clear that needs other than the client's may be influencing the therapeutic process. By failing to address how these breaches of public trust may be inadvertently fostered by the lack of explicit sanctions against post-termination sexual relationships, our association may be offering less than complete protection to the public despite its best intentions.
Possible safeguards for clients and psychologists
Ultimately, the best protection for the public occurs when psychologists have a clear sense of professional boundaries and act scrupulously to maintain them. These boundaries may exist by virtue of the psychologist's character (cf. Jordan & Meara, 1990; Meara, Schmidt, & Day, 1996), their professional socialization, or because of professional codes of conduct and the threat of sanctions should they be violated.
In cases where work with current clients is affected because of situational or characterological problems faced by the psychologist, it is ethically mandatory that the psychologist take responsibility for these problems by seeking the advice of colleagues or supervisors or perhaps considering entry into his or her own personal therapy. These solutions may also require the psychologist to prepare for and eventually transfer any clients whose current treatment may be deleteriously affected (Keith-Spiegel and Koocher,1985).
In other cases, it may not be characterological problems that influence a psychologist's perceptions of his or her current clients so much as the lack of explicit sanctions against any post-termination sexual relationship with them. In this potentially more common type of harmful situation, changes to the education and training of psychologists may be required, along with considerations for modifying ethical practice codes and guidelines to enhance the "once a client, always a client" perspective.
In line with this, perhaps the single best way to ensure that the temptation of a post-termination sexual relationship does not contaminate psychologists' ongoing work with current clients is to socialize them to accept that their clients are "off limits" as sexual partners both during therapy and following termination. This message would have to become part of graduate training programs and internships and be both taught and modelled by trainers and supervisors if not codified by professional associations and regulatory bodies.
Some may argue, quite convincingly, that this would be a difficult if not impossible standard to maintain, and that a possible relationship between two informed and consenting adults is not something that professional associations and regulatory bodies should have the authority to limit (cf. Gabbard, 1994; Lazarus, 1999). Our view is that it is appropriate to hold psychologists to the highest standards of 'behaviour in order to maintain the public's trust and respect for our profession and its contributions to human welfare. It is not clear to us how the public interest is served when psychologists may, at least under some circumstances, develop sexual relationships with people they have treated. It also does not seem like an exceptional burden to ask psychologists to look to places other than their past caseload for sexual partners. As Gabbard (1994) has rather forcefully stated, a lack of prohibition on post-termination sexual relationships might allow some psychologists to "turn a practice into something resembling a dating service" (p. 331).
Given the concerns outlined above, it does not seem unreasonable to consider modifying our current ethical practice codes to increase protection of the public, bring our standards in line with those of the medical profession, and minimize the possibility of contaminating professional functioning through unintentionally permissive wording.
References
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Blackshaw, S.L., & Patterson, G.R. (1992). The prevention of sexual exploitation of patients: educational issues [Online]. Available: http://cpa.medical.org/cpa/public2/papers/position.papers/exploit.html.
Canadian Psychological Association. (1989). Practice guidelines for providers of psychological services. Ottawa: Author.
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Canadian Psychological Association. (2000). Request for feedback regarding the proposed revisions to the Canadian Code of Ethics for Psychologists [On-line].Available: http://www.cpa.ca/ethics2000.html
Epstein, R.S., & Simon, R.I. (1990). The exploitation index: An early warning indicator of boundary violations in psychotherapy. Bulletin of the Menninger Clinic, 54, 450-465.
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