I am beginning treatment of a patient who had a sexual relationship with a previous therapist. What are the potential problems and important things to keep in mind?

Reply from Malkah T. Notman, M.D., Clinical Professor of Psychiatry at Harvard Medical School, Cambridge Hospital, Cambridge, Massachusetts

I have seen a number of patients who have experienced boundary violations with therapists, particularly boundary violations in which a sexual relationship has developed between patient and therapist.

Ms. A, a 38-year-old married woman, came to see me because of depression and feelings of shame following a sexual relationship with a previous therapist. She described having gone to see a therapist several years earlier because of depression she suffered after her mother’s death. The treatment had initially been helpful, but she had been drawn into a sexual relationship with the therapist. When it broke off, she felt intensely angry, ashamed, and depressed.

A sexual relationship between therapist and patient in an ongoing therapy is always unethical. Even relationships between a therapist and a former patient, if the therapist is a psychiatrist, are considered unethical by APA ethics rules. Some terminations are inadequate or opportunistic, and transference feelings remain for a long time.

There can be many degrees of sexual involvement, from erotic hugging and touching to actual sexual intercourse. The patient may be drawn into a relationship by the therapist, or there may be a mutual feeling of "falling in love." But the differential in power and the effects of the transference create distortions in the relationship. It is always the responsibility of the psychiatrist if there is a sexual relationship, no matter how difficult or "provocative" the patient has been.

Ms. A had found herself attracted to Dr. Y after several months of therapy. One wintry day, Dr. Y had offered to give her a ride home. She accepted. She was depressed and found his attention gratifying. He told her she was special to him, and after several months they became involved sexually. She continued to pay his fee and they met in his office.

She, too, felt that it was a special relationship and thought she was the only patient he had chosen in this way. She hoped that Dr. Y would leave his wife and that they would have a life together. He hinted that he would leave his marriage but did not.

After about a year, she learned by chance that he had a relationship with another female patient as well. She became enraged, broke off the relationship, and became even more depressed. She didn’t know what to do and sought psychiatric help as well as legal counsel.

Ms. A wanted help but was very reluctant to enter therapy again. Patients who have had a sexual relationship with a previous therapist can have major problems with trust and can be very mistrustful of subsequent therapy. They may want to change therapists several times. Sometimes a subsequent therapist wants to extend him- or herself and will lengthen the hour, meet at unusual times, or try to make other accommodations. Such changes of the frame can be disturbing to the patient. These patients need to build trust, which can take a long time. Predictability and reliability are important. Patients may hesitate to tell the subsequent therapist anything for a while. Sometimes such patients have been severely traumatized and may need to control aspects of the situation such as the time and the setting. The meeting time and setting need to be negotiated. The setting is best kept neutral or formal, e.g., in the office (1).

It is important for the subsequent therapist to recognize these issues and their meaning and to be consistent and predictable but not rigid. It is also important to realize that although the patient may have feelings of hurt, rage, and disappointment regarding the former therapist, there may be positive feelings as well—and these may or may not be overshadowed by the anger, disappointment, and shame. The patient may have been helped in some way and also may need to protect her choice of the first therapist.

How the patient describes herself reflects this. She may not want to see herself as "victim" or "survivor." There is no one psychological or socioeconomic characteristic to describe patients who have been in this situation, although problems recognizing boundary issues in other situations have been described as leading to vulnerability (2).

The therapist’s countertransference reactions to the patient are important. The therapist can find him- or herself curious, with a voyeuristic interest in the patient’s story, or may develop erotic feelings. The therapist may become so angry at the previous therapist that punitive and angry feelings dominate the therapy, and the patient’s agenda can be lost.

Whether to report the previous therapist to professional societies or seek legal action must be carefully thought about. The patient needs to maintain some autonomy and control where possible. Sexual encounters with therapists are profoundly damaging to patients. The patient needs to resolve the original reasons for seeking therapy as well. Consultations with other psychiatrists can be extremely helpful to both therapist and patient. In spite of the difficulties, subsequent therapy can be an important resource for mastery and healing.