Ethics Rounds

The APA Ethical Principles of Psychologists and Code of Conduct--our ethics code--consists of general principles and standards of conduct, as its title reveals. The general principles set forth the values central to our profession. The ethical standards apply those values to psychologists' day-to-day practice across the broad range of our discipline. When conflicts arise between values, the standards must negotiate among the competing values. Ethical Standard 10.08 is an excellent illustration of how the code accomplishes this essential function.

As a profession, we have learned all too well the harms that occur when psychologists become sexually involved with their clients. The harms are so clear that our code, like the codes of all major mental health organizations, absolutely prohibits such involvements. Sexual involvements with former clients and patients, however, are more complicated from an ethical perspective. Time may attenuate the intensity and even the likelihood that an involvement will result in harm. Permanently prohibiting involvement may compromise the client's exercise of autonomy in determining with whom, and how, to be involved in personal relationships. The issue of sexual involvements with former clients therefore requires its own analysis to determine when, if ever, such involvements may be ethically permissible or, put a different way, whether and to what extent such involvements should be prohibited.

Analyzing this issue requires examining post-termination sexual involvements from at least two perspectives: that of our values and that of our knowledge and data about the dynamics and effects of such involvements--in short, the ethical and clinical/research perspectives. From the ethical perspective, a conflict arises between General Principle A, Beneficence and Nonmaleficence, and General Principle E, Respect for People's Rights and Dignity. The conflict arises because Principle A exhorts psychologists to do good and not do harm, while Principle E exhorts psychologists to respect individuals' right to self-determination.

Note how the code settles this conflict in the case of sexual involvements with current clients and patients; harm is so likely to occur, and autonomy so likely to be compromised in the therapy relationship, that the code establishes an absolute prohibition against sexual relationships. In post-termination relationships, however, given the passage of time, the harm becomes less certain and the likelihood that a client's autonomy will be compromised less clear. Here we see the important relationship between the ethical and the empirical: To clarify and deepen the ethical analysis, we must examine these relationships in light of data.

The possibility of post-termination sexual involvements raises a number of empirical questions directly relevant to our ethical analysis, as the following six examples show:

  • Does knowledge, on the part of the psychologist or the client, that a post-termination sexual involvement is possible, affect the service provided? It will be important to examine whether, and how, such knowledge interferes with effective treatment. It will also be important to assess whether, in cases where post-termination involvements arise, something happens in the treatment to lay the foundation for the subsequent involvement. Such occurrences would almost certainly be counter-therapeutic.

  • How often do patients seek additional treatment with their psychologist after a therapy has ended? This question is important because a post-termination sexual involvement will preclude the possibility of any further professional relationship between the psychologist and client.

  • Are individuals able to exercise a truly autonomous choice to enter into a sexual involvement with a former treating psychologist? The answer to this question will likely depend on several factors, such as the amount of time that has passed since therapy has terminated; the nature, intensity and duration of the treatment; and the individual's personal history, psychological dynamics and current mental status. The degree to which an individual's autonomy is compromised in a relationship with a former treating psychologist, for example, would differ if the treatment were a brief intervention for a specific phobia that ended five years ago, as opposed to a psychoanalysis that terminated in the past month and that had addressed a significant history of sexual exploitation at the hands of a trusted authority figure.

  • Under what circumstances do post-termination sexual relationships result in harm? This question is centrally important because the first general principle of the Ethics Code involves nonmaleficence: Psychologists strive to do no harm. Note the close relationship with the question above. To the extent that an individual's autonomy is compromised, that individual may be less able to avoid entering into harmful or exploitative relationships.

  • Is there a consensus among psychologists about whether post-termination sexual involvements are ethically problematic? Strong agreement among psychologists of different theoretical and technical orientations would suggest a considered professional judgment concerning whether such involvements lead to exploitation or harm.

  • When are post-termination involvements most likely to occur? If the majority of involvements occur when autonomy is most compromised and harm is most likely to occur, it may make good ethical sense to create a heavy presumption against post-termination involvements.

Note three things about Ethical Standard 10.08. First, by creating an absolute prohibition against sexual involvements for two years post-termination and then placing the burden on the psychologist to demonstrate that the involvement is not exploitative, the standard gives priority to nonmaleficence while leaving room for the exercise of client autonomy. By setting forth clinically based criteria relevant to assessing whether harm is likely to occur, paragraph (b) confirms this balance of values, emphasizes the importance of avoiding harm in these relationships, and provides concrete direction in how to assess the likelihood of exploitation.

Second, evidence available at the time standard 10.08 was written suggests that the significant majority of these involvements take place within two years of termination. The two-year absolute prohibition immediately following termination is when a client's ability to exercise a fully autonomous choice with regard to a former treater seems most likely to be compromised, and when sexual involvement that had been suggested explicitly or by innuendo during treatment would most likely come to fruition. In this manner, the standard is founded upon data about how to avoid a very high percentage--perhaps nearly all--of potentially harmful relationships.

Third, standard 10.08 illustrates how our ethics and our evidence can be closely related. Over time, data may emerge that speak to the questions above in a manner that recommends an absolute prohibition against post-termination sexual involvements. In the alternative, the evidence may suggest that relaxing the prohibitive aspects of the standard is appropriate. In whichever direction the standard evolves, its evolution should rest upon solid clinical thinking and good research.

10.08 SEXUAL INTIMACIES WITH FORMER THERAPY CLIENTS/PATIENTS

(a) Psychologists do not engage in sexual intimacies with former clients/patients for at least two years after cessation or termination of therapy.

(b) Psychologists do not engage in sexual intimacies with former clients/patients even after a two-year interval except in the most unusual circumstances. Psychologists who engage in such activity after the two years following cessation or termination of therapy and of having no sexual contact with the former client/patient bear the burden of demonstrating that there has been no exploitation, in light of all relevant factors, including (1) the amount of time that has passed since therapy terminated; (2) the nature, duration, and intensity of the therapy; (3) the circumstances of termination; (4) the client's/ patient's personal history; (5) the client's/patient's current mental status; (6) the likelihood of adverse impact on the client/patient; and (7) any statements or actions made by the therapist during the course of therapy suggesting or inviting the possibility of a post-termination sexual or romantic relationship with the client/patient. (See also Standard 3.05, Multiple Relationships.)

Further Reading

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