The boxed part of Fig. 28.1 is the part that is relevant when it comes to professional counseling. People go to a therapist to solve a problem they cannot solve on their own. If there is only involvement and good communication but no problem-solving or collaboration, the working relationship is inadequate. However, if the patient arouses such strong positive or negative emotions in the therapist that the relationship does not remain limited to problem-solving, then there is excessive emotional involvement. An unmanageable intimacy comes into being, sometimes also erotically charged. For instance, a therapist asks (out of curiosity) about sexual details, even though this is not going to lead to a better understanding or more effective approach to the problems. In doing this, the therapist is violating the patient’s privacy. Another example is the overinvolvement that may arise when the therapist is working with a couple, as is regularly the case in sex therapy. The therapist then ends up in a “love triangle” with the two patients and starts to act as a lightning rod for the tensions in the relationship between the two patients [4].
Talking about intimate matters sometimes creates a form of intimacy that in everyday life goes with erotic contact. In therapy, sexuality and intimacy as topics of conversation can easily lead to crossing boundaries, showing behavior that deviates from what is regarded as normal, proper, or predictable. In spite of the clear position of all professional associations and of statutory provisions that sexual contact between the therapist and patient is always absolutely prohibited, it still occurs frequently, and many examples have been described, particularly in the reports of disciplinary proceedings, of therapists drastically overstepping boundaries. It is not a new phenomenon either. However, interest in it has increased in recent decades. A review by Wilbers et al. showed that 5-10 % of male doctors had had sexual contact with a patient once or more often [20]. Leusink arrived at a figure of 4 % among Dutch GPs [22]. Pope found a similar percentage for male psychologists and social workers in the United States [23]. Sexual contact between female therapists and their patients is considerably less frequent, with figures ranging from 0.5-1.5 %. Various studies have also shown that actual sexual contact with patients is only the tip of the iceberg. Feeling sexually attracted to and having sexual fantasies about patients are very much more common. Almost 80 % of male therapists sometimes feel sexually attracted to a patient, and over half of them also have sexual fantasies [20, 22, 23]. For these parameters the percentages for female therapists are again significantly lower. Approximately a third of them sometimes feel sexually attracted to a patient. On the basis of research, official reports, and case histories, Pope [23] described a few scenarios that increase the chance of violating sexual boundaries, such as:
The therapist becomes a “patient” and the focus in the therapeutic relationship shifts to the therapist’s emotional and sometimes sexual needs.
The therapist takes on the role of protector: He or she arranges everything for the patient, playing the role of the great “carer,” but at the same time starts to tell the patient how to feel and act. As a result, the therapeutic relationship provides a false security, which blocks the patient’s therapeutic growth.
Key Points
Therapists should safeguard their own boundaries by remaining critical and maintaining sufficient emotional distance from the patient’s experience and person. Overinvolvement and overstepping professional boundaries can pose a serious threat to the therapeutic relationship.
The guidelines and statutory provisions relating to these matters are very clear: A therapist may not have a private relationship and may certainly not embark on a sexual relationship with a patient.
28.6 The Therapeutic Process
The pillars of the bridge to the patient’s own competence and problem-solving capacity are safety, challenge, and empowerment—safety as a prerequisite to being able to achieve change, challenge as a vehicle of this change, and empowerment as a lever for change. Roughly speaking there are three kinds of interventions available to provide patients with safety, challenge, and empowerment: support, structuring, and confrontation. Support creates safety and is also a strong source of empowerment. Confrontation leads the patient to accept the challenge. Structuring not only provides a solid footing and control and therefore safety but also a frame of reference for implementing and empowering changes in thinking, feeling, and acting [24–26].
28.6.1 The Therapeutic Relationship as a Safe Haven and Playing Field
Cormier and Hackney distinguish four basic functions of the therapeutic relationship [27]. In the first place, the therapeutic relationship provides a safe situation in which patients can express themselves and be vulnerable. In the second place, the therapeutic relationship is a medium for arousing strong feelings in the patient and helping the patient to deal with these feelings and gain control of them. Arousing strong feelings and ensuring they are expressed are often necessary to initiate a process of change, but the patient must feel protected, understood, and respected in this situation if he or she is to be able to accept this challenge. This also applies strongly, for example, to the loss of sexual functions after gynecological cancer treatment or to memories of sexual abuse. In the third place, the therapeutic relationship can have a significant empowering and motivating function for the patient. The feeling of no longer having to face the problems alone can often mean a breakthrough. In the fourth place, the therapeutic relationship can function as a model. The patient can see how pleasant and helpful an interpersonal relationship can be if it is possible to work constructively on solving problems within such a relationship. The therapeutic relationship also provides a “playing field” where the patient can practice certain skills before applying them in real life. With respect to communication in particular, the therapist can serve as a role model and the therapeutic relationship as a practice situation which can be very valuable. However, a prerequisite is that everyone involved is fully aware that this is, in fact, a practice situation that is completely separate from the rest of ordinary life. If this is not the case, then it is only a short step from providing safety and sharing intense emotions to boundary-crossing behavior.
Case History: Continued
An Exceptional Night
One stormy evening Professor Schwartz has just gone to bed when the telephone rings. Somewhat disorientated, he hears her now familiar voice. Obviously that evening emotions had been running high at the Vs’ place, since Mrs. V—now known as Linda to Professor Schwartz—tells him, sobbing, that she is in the car and is not sure where she is. After another heated argument she had run out of the house, furious, and gotten into her car. She had driven around aimlessly for a while and is now parked in a car park, at her wits’ end.
“I’m not going back, I’d rather jump in front of a train,” she says desperately.
Schwartz tries to calm her down and after a few more expressions of anger, she seems to calm down. “I think I’m not far away from your place now. Would you mind very much if I came to see you, because I don’t know what else to do. I just ran away. I haven’t got anything with me and I can’t really turn up at a girlfriend’s place like this.”
Before thinking about all the implications, Schwartz agrees. “Of course you’re welcome here. I was still awake anyway.” Fortunately he does have a moment of reflection. “Linda, you can stay in the guest room, but please let your husband know you’re with me.”
When Linda turns up at his door a short time later, she doesn’t look very happy, but she has calmed down again. Schwartz has quickly put some clothes on and invites her into his consulting room. Over a cup of tea they talk about what happened at the Vs’ place. Schwartz doesn’t want to talk for long, because by now he is very tired and tomorrow his patients at the outpatient clinic will be waiting for him. He does ask Linda if she has let her husband know where she is. Linda is a bit vague about this. Yes, she had intended to, but she does not want to talk to him on the phone now. She will send him a text message.
Schwartz shows her where the guest room and the bathroom are and then goes to his own bedroom for a few hours of sleep. It is now 2.30 a.m. and at 6.30 the alarm will go off.
In sex therapy there are significant advantages to working with couples rather than with individuals. In the first place the therapist can gain a better understanding of both the nature and the consequences of the complaints or problems. This is important, because problems can be not only both cause and consequence but also a solution. Sometimes patients, but sometimes also both partners, perpetuate problems. In the second place, it is easier to make the transfer from the therapy situation to the everyday private situation. For the couple, the therapist is mainly a catalyst for having positive experiences of communication and coping with problems so that they can build on these experiences in their daily lives. Moreover, it prevents the boundaries of professional involvement from being crossed and undesirable intimacy from entering into the therapeutic process, with all the damaging effects that can have [23]. The therapy situation itself is not always suitable for exercises or assignments. For instance, sexual assignments should be done in the patient’s private life.
28.6.2 Therapeutic Power
There are many possible reasons why a therapist’s interventions do not sink in with the patient or why the patient fails to follow them up. All such disruptions in a patient’s attention, capacity to comprehend, and ability to change emotions and behavior are covered by the term “noncompliance.” Noncompliance certainly does not necessarily mean active rejection of the therapist’s insights and interventions. Following Lange, we can distinguish between processes such as habituation, other concerns, lack of attention, or forgetting that result in failure to follow therapeutic suggestions and the more active opposition arising from intrapsychic or interactional motives that conflict with the stated therapeutic goals or methods [28]. This active form of therapy noncompliance is referred to as “resistance.” It may involve unconscious processes, but it may also entail an open refusal to follow certain instructions or to continue therapy.
Case History: Continued
An Exceptional Morning
The next morning Schwartz feels fairly exhausted and also ambivalent about Linda staying the night. There is still no sound from the guest room, and while drinking his first cup of coffee, he thinks about what has happened. It dawns on him that he is very captivated by Linda and that he has not felt such a strong connection and need for intimacy with a woman since the death of his wife. On the other hand, he is also very much aware of the delicate situation that has now arisen. Not only for himself but certainly also for Linda, the therapist–patient relationship is shifting toward friendship and even toward a relationship with erotic overtones.
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