Misinformation can damage patient outcomes
By Ofer Zur, Ph.D.

There is an inherent power differential

    From the first day of graduate school in psychology, psychotherapists-in-training are instructed to pay great attention to the “inherent power differential” in psychotherapy. They are taught to be aware of the imbalance of power between a therapist and his or her client, and are repeatedly warned against inadvertently abusing or exploiting vulnerable and dependent clients.

    The idea of power as an attribute possessed exclusively by the therapist goes largely unchallenged. Our professional newsletters and advice columns on ethics and risk management present a similarly unified message about therapists’ unilateral power and clients’ inherent vulnerability.

    Many psychotherapy clients, and those who are mandated to undergo different types of forensic evaluations, are very vulnerable because of the power differential that exists in these professional relationships. These clients may be distressed, young, impaired, traumatized, psychotic, anxious and/or depressed.

    There are also clients who function highly – emotionally and psychologically – and are as, or even more, powerful and effective than their therapists. They may be wealthy investors, powerful CEOs, established artists, forensic experts or simply very centered, solid humans beings who seek therapy to find meaning, their highest potential in a certain arena or a closer relationship to God.

    They are not depressed, traumatized or vulnerable. It is important to note that most therapists are one borderline (BDP) away from losing their licenses. Therapists must know the difference and remember that not all clients are created equal.

 

Physical touch is unethical

    Therapists are told by risk management and ethics experts, attorneys, continuing education instructors and supervisors to never touch a client beyond a handshake. Touch has been increasingly perceived as a risk management issue to be avoided rather than as one of the most powerful ways to connect with and heal clients. The notion that non-sexual touch is likely to lead to a sexual relationship is countered by greater understanding of the importance of touch for human connection and bonding and in reducing stress, anxiety and depression.

    Despite 50 years of extensive knowledge on the emotional, relational, physiological and behavioral benefits of touch, many (if not most) therapists still shy away from appropriate non sexual touch due to fear. Even though most therapists touch their clients by patting them on the back, holding a hand or giving an appropriate hug at the end of a session, they do not write or talk much about it.

    The good news is that clinicians are increasingly open to looking at the benefits of touch with those who are depressed, anxious and stressed, as well as clinically appropriate touch with children and even with women who were sexually abused.

 

Risk management is part of

the standard of care

    Effective risk managers don’t:

    • Touch

    • Leave the office

    • Give or accept gifts

    • Barter

    • Self-disclose

    • Engage in dual relationships

    • Make home visits

    None of the above “don’ts” are inherently below the standard of care for psychotherapy. Risk management is promoted, primarily, by insurance companies to reduce their possible liability.

 

Distance care is new

    Distance care, also known as telemental health is not new. Perhaps one of the earliest examples is Freud’s letters exchanged with “Little Hans” in the late 1800s and thousands of personal, self-analysis letters. Some more modern examples include:

    • Suicide prevention, domestic

        violence and other crisis hotlines

        and lifelines

    • Telephone therapy, established

        in 1960

    • Warmlines

    • Television therapy, for example

        Dr. Phil

    More recently, there has been an explosion of pandemic-inspired telemental health services and social media and text therapy have emerged as options.

 

Dual relationships are always unethical

    “Dual relationships” in psychotherapy refers to any situation where multiple roles exist between a therapist and client. Examples include when the client is also a student, friend, family member, employee or business associate of the therapist. Psychotherapists making custody recommendations (i.e., engaging in a dual role of therapists and experts) is one of the most common, appropriate reasons for psychotherapists to be disciplined by licensing boards. Clearly, forensic psychologists who conduct forensic evaluations, such as sanity to stand trial or custody evaluations should avoid dual relationships of any form.

    Non-sexual dual relationships are not necessarily unethical or illegal. Sexual, exploitative and harmful dual relationships are unethical and can be illegal. Most of the major professional associations’ codes of ethics state that multiple relationships should be avoided only if they could reasonably be expected to impair the therapist’s effectiveness or cause harm to clients.

    There are several kinds of dual relationships – unavoidable, or mandated; consecutive or sequential; expected or unexpected accidental; initiated by therapists or clients and they can be of low, medium, or high intensity.

    Dual relationships are often unavoidable in rural, small and minority communities, the military, church and AA, NA and LGBTIQ communities. All major mental health organizations’ ethical guidelines do NOT mandate a blanket avoidance of dual relationships. All guidelines do prohibit sexual dual relationships with current or 2 to 4 years post termination.

 

The slippery-slope argument

The baseless and paranoid idea of the “slippery slope” has been with the field of psychotherapy for too long time and, when followed, results in substandard care. It is unwise to assert that non-sexual touch is likely to lead to sexual touch; that simple gift-giving results in social relationships; or that bartering inevitably ends in exploitation.

    Malpractice lawsuits are common and something to be concerned about Therapists have been indoctrinated to fear lawsuits and licensing boards. The fact that social workers, MFT’s and counselors pay about $300-$400 a year for malpractice insurance and psychologists pay about $1,200 a year, while many cardiologists, anesthesiologists and obstetricians pay $50,000 to $80,000 or more a year clarifies the gap in the level of risk between psychotherapists and some physicians.

    The number of complaints to licensing boards is not as high as many attorneys and “ethicists” lead us to believe. Even when charges are brought, many complaints are dropped without any charges being filed and without the therapist knowledge.

 

Telemental health reduces the risk of therapists violating boundaries

    Many people, when online (e-mail, text, social media, phone), self-disclose or make up stories significantly more than they would in person. There are several factors that interact with each other in creating this ‘online disinhibition effect,’ including anonymity, invisibility, imagination and minimization of authority or common sense. In last few years, the disinhibition effect has, clearly played a role in board and civil cases. Late-night and other unethical communications and excessive self-disclosure are clearly sub-standard care. They are impossible to defend as they unethically blur personal and professional boundaries.

 

It is never, ever ethical to be naked with a client

    Most, if not all, therapists, experts and people in general are likely to respond with a strongly in the negative as they probably connote this situation of therapist being naked with client, with a unethical or illegal sexual encounter.

    Obviously, sex with clients is ALWAYS unethical, counter-clinical, and illegal in most states. Then imagine a situation in which a therapist is stepping out of the shower stall in the local gym when, to his or her or great surprise, a client (equally naked) steps out of the next stall. This is called an “incidental contact,” “chance occurrence,” or what I call an “out-of-office experience” that takes place in the community, outside of the treatment room. Such nude encounters have been reported to have taken place at nudist beaches or at the hot tubs in retreat centers or gym locker rooms.

    This section is an example of how therapists and ethicists must first understand and comprehend the specific context of each and every situation BEFORE they cast uninformed, ‘instinctive’ judgment.