Q. I have an unusual question regarding the ethics of the doctor-patient relationship. I have a friend who was seeing a psychiatrist about 10 years ago following her divorce. Since that time, she has seen 3 more different therapists, and thankfully, she is all better now.

It seems to me that 10 years and three therapists removed is a long time ago. Can you offer some guidance on the professional guidelines on this matter, if there is any?

A. There are professional guidelines that apply to the psychiatrist your friend is dating--basically, they say no to this relationship, as difficult as that may be for both parties.

I think it is appropriate to quote one of the most respected psychiatrists in the U.S. on this matter, from his recent review. Dr. Glen Gabbard writes, "...The role of an ethics code is to proscribe professional misconduct that may have the potential to harm the patient. Because we know that in many cases of psychiatrist-patient sex there is serious exploitation of the patient's vulnerability, we have clear prohibitions against sexual relations between a current patient and his or her psychiatrist.

"The same considerations apply to former patients. The transference (and countertransference) feelings [strong and often unconscious feelings experienced by the patient and therapist, respectively] established in the relationship persist well beyond termination. Even in the absence of a treatment that acknowledges the existence of transference, a power differential is unmistakable because of the fiduciary nature of the relationship. Moreover, the therapeutic relationship is effective because it will never be anything but a treatment relationship. The possibility of a future sexual affair between psychiatrist and patient erodes the conditions necessary for effective psychiatric therapy.

"Finally, most patients will feel the need to return to treatment at some point in the future, and the psychiatrist needs to preserve that potential as part of the duty to the patient. For all of these reasons, the current position of the APA [American Psychiatric Association] on an absolute prohibition against sex with former patients is a sound and sensible one." (Psychiatr Clin North Am 2002 Sep;25(3):593-603).

Of course, all this is sometimes easier to advocate in theory than to carry out in the unruly world of human emotions--and perhaps the intervening therapists your friend saw adds a complicating factor to the equation. And yet, I think we need to stick by our professional standards, even when the heart asserts its own wishes.

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July 2003

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