Robert M. Gordon,Ph.D. ABPP

On the occasion of the American Psychological Association revising their ethical code for the tenth time since 1953, it is my contention that, by necessity, as more psychologists have entered private practice, the ethical code has had to change to become more like the psychoanalytic ground rules. This progression is a sort of unintended validation of standard psychoanalytic practice, as useful to all treatment situations.

Freud (1912, 1913) described in great detail ground rules of therapy and the boundaries of the therapist-patient relationship. The rule of neutrality is to help guard against the analyst’s own feelings, biases and values affecting the treatment. The rule of abstinence is to deny any inappropriate gratifications in the therapeutic relationship for either the therapist or the patient, so therapeutic work does not get derailed. Fees are not looked at as something apart from the therapeutic relationship, but a critical aspect of the treatment itself. A devious, unfair or overly lenient fee arrangement is a powerful factor in treatment outcome. In the psychoanalytic relationship confidentiality and privacy is absolute, except in life-threatening situations. Extra-analytic contacts are avoided.

More recently, Langs (1976) has elevated Freud’s basic ground rules to the “secure frame”, without which patients never trust the therapist enough to work through deep level conflicts. Langs makes the secure frame the main factor in therapy. In Langs’ (1976) summary of the psychoanalytic literature, the protection of the transference in the secure frame is essential for therapeutic results.

No other theory of personality, psychopathology or treatment demands so much from the therapeutic relationship as does psychoanalysis. No other psychotherapeutic system involves as many ground rules that stem from its cohesive theoretical formulations. Psychoanalytic theory has evolved treatment conditions that are as inherently ethical as they are therapeutic. This I believe is because psychoanalysis is not a science of what is conscious and manifest, but what is unconscious and latent.

There is reason to expect problems when the relationship is limited to only what is superficial. People will always try to repeat the symbolic past in relationships. Psychoanalysis is based on this assumption and acts to protect the symbolic nature of the relationship, not only to be proper, but to promote a therapeutic alliance. This promotes a very ethical practice that is empathic with the needs and not the demands of the patient. It is assumed that the patient will demand gratification from the relationship, but needs to work through the past in the symbolic relationship. To protect this symbolic relationship is to protect the patient. This provides the theoretical link between psychoanalytic treatment and ethics.

Wallwork’s recent book, Psychoanalysis and Ethics (1991), argues that Freud’s discoveries have made us aware that unconscious motivations may subvert moral conduct and that moral judgements may be rationalizations of self interest or expressions of hostility He quotes Julian Huxley: “The greatest change since 1893 in our attitude towards the great problems of ethics has been due to the new facts and new approach provided by modern psychology; and that in turn owes its rise to the genius of Freud.”

Wallwork demonstrates that although Freud was very critical of a superego- determined ethic, his work supports an ethical theory based on a concept of regard for others, concerned with common good, special relations, and individual rights.

Freud once commented that people might disagree with his theories by day, but dream according to them by night. Likewise, many non- and anti-analytic therapists may be critical of Freud’s theories but will have to practice by many of his ground rules, if they wish to avoid unethical practice. I believe that any psychological treatment would be enhanced within the psychoanalytic frame. Even in behavioral therapies and advice-giving counseling where the technical neutrality is compromised, the basic ground rules are just as relevant and necessary, because the basic nature of people does not change from therapy to therapy. The professional and incorruptible image of the therapist makes it safe to work with the therapist on a meaningful level, regardless of the type of therapy.

But since a code of ethics is not a theory of personality, psychopathology, and therapy, it lends itself to rigid superego-type thinking. Complex issues can become a matter of “by definition it’s unethical, ipso facto”. It is much better for these reasons for proper conduct to be part of a comprehensive theory of conduct. This shift allows for a better understanding of human interaction and its consequences. And in the most pragmatic sense, when a sanctioning body has concern over a breach of ethics and is deliberating a course of action, it helps to understand the meaning and consequences of the behavior, not just simply to judge it.

Later, I will give examples of using the notion of protecting the transference, that is the symbolic and incorruptible nature of therapeutic relationships, to help better deal with ethical situations. It is my hope that this essay will help promote more consideration of not only a theoretical underpinning of ethical behavior in psychotherapy, but also suggest a useful framework for ethics and sanctioning boards in understanding and handling certain situations concerning therapist-patient interaction. This paper is limited to those ethical issues relating to the therapeutic situation.

Evolving Ethical Standards

Although most people will say that they are ethical, we know that people can rationalize anything, and act in unethical ways. As professionals who treat the public, it is important to establish agreed-upon guidelines of ethical conduct. These are notions of the culture’s and the professional society’s concept of what is good, proper or acceptable. These are very special guidelines because of the special work that we do. So that special ethics, above and beyond the usual ethics expected of civilized people, are required of the psychotherapist. Although ethics are not laws, an ethical code allows for a professional society to educate its members, or exclude unethical individuals from membership. State licensing boards have adopted ethical codes into their regulations, and thereby have the power to demand fines, supervision, psychotherapy, suspension or revocation of the license to practice. Unethical conduct can be a relevant issue in a malpractice suit.

Since ethical standards are evolving along with a greater acceptance of concepts and implications of transference and countertransference, it may not be fair to judge someone’s past actions which took place before the current ethical guidelines.

Example: A psychologist was being investigated for having sex with one of her patients. The psychologist was trained in Gestalt therapy, and there was frequent sexual contact between students and teachers and therapists where she had trained. This was in the early `70’s, a period marked by a great deal of experimentation and acting out. This incident occurred early in her career, with a very manipulative and seductive patient. She states that there has been no other incident since. The, therapist eventually adopted a more analytic approach after, as she put it, “learning the hard way about transference and countertransference”. The complaint was made about fifteen years later, with the encouragement of the former patient’s new female therapist. No action was taken, mainly because it had occurred before the change in APA’s ethical code that specifically forbid sexual contact with a client or patient.

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Ethics Based on Principles

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Although I argue that ethical conduct between a therapist and patient should be based within the comprehensive theory of psychoanalysis and within the concept of protecting the transference, particular ethical principles should be delineated. The newly proposed 1991 version specifies six basic principles: 1) Competence, 2) Integrity, 3) Professional responsibility, 4) Respect for people’s rights and dignity, 5) Concern for others’ welfare, and 6) Social responsibility. In APA’s prior codes of ethics, the principles were not all principles but headings, for example, “Principle 3: Moral and Legal Standards: Principle 4: Public Statements; Principle 7: Professional Relationships”, and so on. This new set of ethics is rightly based on given values which in turn lead to specific applications to proper conduct. They are essentially based on the Hippocratic Oath’s ethic of “first do no harm” and then “do good”.

There is no statement of a good business work ethic that encourages financial rewards and that makes being a therapist worth all the extensive education and training. Certainly the practice of psychology is intellectually and emotionally rewarding. But if it is not financially rewarding, as well, will we be able to attract 
good people to the field? Acting in reasonable self interest and good business sense should not necessarily conflict with ethical codes which are primarily set up to protect others and help the profession look dignified. But when they do conflict, the ethical principles make it clear that the values of competence, integrity, responsibility, respect, concern for others’ welfare, and social responsibility supersede the values of profit.

 

Example: Recently the APA code of ethics had to change its restrictions on advertising so that it didn’t conflict with Federal free trade laws. In addition to the expected prohibitions against advertising being false, deceptive, misleading or fraudulent, now even testimonials are allowed, as long as they are not from current patients. (This is to protect the therapeutic relationship with the patient.) This is a good example of a guild’s value of a dignified public image giving way to a Federal law to protect and encourage enterprise. A testimonial from a current patient, however, exploits the relationship. Here the value of protecting the patient prevails. However, the psychoanalytic ground rules would extend to even former patients.

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The Principles

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1) Competence means that we should know what we are doing. Since we do new things, we should get proper education, training, supervision and/or continuing education.

Example: A therapist decides after years of practice to specialize in psychoanalytic psychotherapy after having been trained in a non-analytic model. Psychoanalytic societies have standards of practice specifying the necessary requirements to be a formal member of that society. One is on safest grounds by obtaining a recognized credential or becoming a member of a professional group that specifies standards for membership in a specialty such as psychoanalysis. But what about areas that are not well defined, such as specializing in psychoanalytic therapy, but not becoming a “Psychoanalyst”? APA’s Competence Principle goes on to state that “...in those areas in which recognized professional standards do not yet exist, psychologists exercise reasonable judgement...”. The psychologist who chooses to specialize in psychoanalytic psychotherapy should get training and supervision in that area to ethically be considered competent to practice that specialty. Community standards certainly are a factor. A psychologist practicing psychoanalytic psychotherapy in the New York City area has little excuse for not seeking training and supervision, as compared to a psychologist practicing in an area where there are no formal training centers. The New York regional area community standard of practice would be considered much higher than, say, in a remote rural area. In this later situation, readings, workshops and paper sessions would be very important in developing competence.

After serving for several years on and as chair of an ethics committee and being involved in the treatment of psychotherapists, I have found that in addition to personal conflicts, there are more ethics’ violations with the least trained and credentialed members of the profession. Although ethical violations occur within every specialty, those individuals with the least competence and who identify with treatments that emphasize the gratifications from the real relationship versus protecting the symbolic nature of the therapeutic relationship are more likely to act out.

 

2) Integrity. We strive to be fair, honest and respectful. We cannot be deceptive in stating qualifications, services, fees, etc. It is unusual analytic practice to simply state policy regarding fees, cancellation, vacations, coverage, appointment times at the beginning of treatment. The principle also states to be upfront with qualifications. How does a therapist protect anonymity when a person calls and asks about a therapist’s credentials? The therapist must honestly respond to reasonable questions about his or her qualifications and credentials. Not to do so or to exaggerate one’s qualifications can lead to trouble. However, personal data is not a reasonable consumer question. Self disclosures are rarely helpful and frequently more harmful than therapists suspect.

 

Example: A patient starting marital therapy asked his therapist if he were married. He stated, “I don’t want someone who was never married doing marital therapy with us.” The therapist told him that was a sensible question, but that in order to do good treatment, he should only know about the therapist in his professional capacity. The therapist said that although he did not consider that question very personal, it does establish a bad precedent if he answered it. What followed was an important discussion on the patient’s use of beliefs versus reality testing regarding trust. This is protecting the transference, necessary for good treatment. If in the beginning of therapy he asked about the therapist’s credentials, although it is probably a derivative about transference and trust, the question must at that time be dealt with as a fair consumer question. If marriage were a requirement of doing marital therapy, then the therapist would also have to answer that question. But to begin to self disclose would surely later be used in the service of resistance. It could come in the form of, “if you already told us that you are married, but refuse to tell us if you have had these problems also, it must be that you do but you are being on the defensive and won’t admit it”. Wherever you draw the line on self disclosure, the patient will be insatiable, and assume the worst about you, if you are inconsistent. The therapist’s anonymity protects the transference and the working relationship.

Under the “Integrity” principle it states, “Psychologists strive to be aware of their own belief systems, values, needs, and limitations and the effect of these on their work.” I consider this brief sentence one of the most important principles of ethical practice. Most of the other aspects of ethical behavior have to do with those conscious behaviors that are part of formal education and training. But being aware of one’s own beliefs, needs, biases, limitations, conflicts, etc., implies what’s going on inside the head of the therapist, the kinds of phenomena that are often unconscious, repressed, denied, rationalized and acted out.

The code goes on in later detail stating under “1.13 Personal Problems and Conflicts...Psychologists recognize that their personal problems and conflicts may interfere with professional effectiveness...(and) refrain from...inadequate service or harm...psychologists have an obligation to be alert to signs of, and to seek assistance for, their personal problems at an early stage...” Although this needs to be stated, so that psychologists are always responsible for their actions, it is during periods of regression and acting out that denial is so great. Many graduate schools tend to be anti-analytic, and the students are neither adequately educated about transference-countertransference, nor are they encouraged to have some sort of personal insight therapy to help identify their personal issues, so that they can at least recognize what gets triggered, what their defenses are, and how to cope with their issues so that they are less likely to get acted out.

Freud’s concept of neutrality is relevant to this principle of integrity. More basic than limiting interventions to mainly interpretations is the respectful consistency of the analyst. The therapist’s neutrality simply means a concern for the patient, without prejudice or bias of any sort.

Finally, under “Integrity” is the statement, “Psychologists avoid improper and potentially harmful dual relationships.” “Improper” can be a matter of opinion, so in recent years various professional societies, including APA, have specified that sexual relationships with a patient are improper. Specifically, you can’t have sex with current patients, or treat former lovers. The APA code is currently still considering how to deal with the issue of sex with former patients. Due to the wide range of thinking on this issue, the proposed draft gives two specific options for your comment. Option 1 is part “a” only; Option 2 consists of both part “a” and part “b”. Part “a” states that sex with a former patient is so frequently harmful and presents a poor image of the profession to the public, it shouldn’t be done, “except in the most unusual circumstances”. The psychologist who engages in such activity bears the burden of demonstrating that the patient was not harmed. Factors include time passed, no exploitation, nature and duration of therapy, circumstance of termination, history, mental status, and adverse impact on others. In other words, the issue is harm, not the act per se. Option 2 is cut and dried and legalistic, but not realistic. “In no case may a psychologist engage in sexual intimacies with a former psychotherapy patient or client within one year after cessation or termination of professional services.” Complexities are avoided, but it seems very naive about two consenting adults waiting 12 months to have sex. The following are two examples of unethical sexual conduct, with the former being criminal and the latter being within ordinary human acceptability.

Example: A psychologist whose theoretical beliefs encourage the acting out of primitive needs, seductively encourages his patients to express their sexual feelings to him, and self-discloses his feelings in return. This is a narcissistically motivated bias to fulfill the therapist’s needs, and not the patients’ needs to integrate conflicts in a mature fashion with a trustworthy therapist. The therapist frequently has sex with his patients. Many of the patients are harmed, feeling used, exploited, betrayed and abandoned. This therapist violates the analytic rules of neutrality by siding with acting out, anonymity by self-disclosure, as well as obvious sexual contact. The transference is not protected, and patients are harmed, not because of the sex, but because of the meaning of the sex, its hostile exploitativeness and insensitivity.

Example: A psychologist has a high functioning patient in supportive therapy for a recent life crisis. After brief therapy has terminated, they meet on several occasions in their rural community’s church and super market. After several months, they meet at a party. They have much in common and get along very well. They date. Eventually, they marry.

In the first example, the therapist is disturbed and exploiting vulnerable patients. Harm was done. In the second example, both individuals are mature, and there was no exploitativeness. Whatever might have been lost in the opportunity for the patient to return to the therapist for further work, or whatever conflicts were reinforced due to transference gratification, or whatever impression was given to the community about therapeutic relationships, were minor compared to the rewards of the relationship for both individuals. Unethical, perhaps. But hardly so. These examples dramatize that the issue is not the act of sex per se, as an immoral act, but rather the meaning of the act in the context of the particular people, circumstances, time and place.

Psychoanalytic theory allows for a diagnostic assessment of the patient which leads to understanding the different effects sex with a patient or former patient can have. A sexual relationship with a borderline patient may not produce any harm until it is broken off. The gratification and then the abandonment would commonly produce a severe regression in the borderline patient. The neurotic patient may deal better with the pre-oedipal issue of loss, but experiences a great deal of guilt and anger over oedipal issues of seduction and betrayal. Higher functioning patients may have no serious iatrogenic effects of a mutually agreed upon sexual affair, with the only harm coming from the destruction of the therapy. Without a good theory it is hard to understand why it is devastating in some cases, not a good thing in most cases, and even possibly harmless in others.

3) Professional Responsibility. “Psychologists uphold high professional standards of conduct...cooperate with other professionals and institutions ...Psychologists’ morals and conduct are personal matters...except as psychologists’ conduct may compromise their professional responsibilities or reduce the public’s trust in psychology and psychologists.” The professional image of Psychology as reputable and trustworthy is essential to our work in helping others.

Example: At the end of a session, a patient asks her therapist to make out the receipt with the next day as the day of the treatment. The patient explains that she wishes to use the receipt as proof to her husband that she spent the time in therapy, and that she is planning to use that time to be with her lover. The therapist refused to do this and told the patient that she could not act in a way to encourage the affair. The therapist was acting in a responsible manner, in keeping with ethical principles. But the added notion of protecting the transference would have helped the therapist give the correct interpretation, and avoid the violation of neutrality in admonishing the affair. It would have been better if the therapist had said that she could not do such a thing in her role as a therapist and look for the opportunity to talk about it the next session rather than prolong the session. The proper interpretation would involve a transference interpretation about the patient’s need to corrupt the therapist. Any devious insurance or fee arrangement communicates to the patient that the therapist is not trustworthy. Such “favors” eventually sabotage the treatment.

 

4) Respect for People’s Rights and Dignity. This principle is expressed in the particular issues around confidentiality, privacy, self-determination, sensitivity to culture, age, gender, race, ethnicity, religion, etc. Psychoanalytic ground rules of strict confidentiality, protection of privacy and technical neutrality is inherently respectful of people’s rights and dignity. A basic assumption of analytic work is to help reduce a person’s tendency to resist learning from experience, and transferring the past on to the present, all of which interferes with personal growth. How a person should live or what they should do, outside of being reasonable, is not a matter for analysis.

The issue of strict confidentiality and privacy is not just an ethic, but a necessary condition for the trust and therapeutic regression in deep analytic work.

Example: A patient who is a college student stated that his father insisted that since he was paying for his son’s therapy, he felt he had the right to have a progress report from the therapist. The father threatened to stop paying for the therapy if the therapist refused to meet with him. Although the patient was willing to waive some confidentiality for the sake of continuing the therapy, the therapist insisted on maintaining the privacy of the therapy. The therapist interpreted that the father did not see the son as a trustworthy source of information, that the father’s need to destroy the therapy will not be quelled by seeing him, and that most important, the patient’s own resistance is being expressed by the father. Eventually, the patient admitted that his anger was toward the therapist for refusing to see the father and jeopardizing his therapy, and not towards his father. Once the patient acknowledged that he was looking for a face-saving way out of treatment, and his father gave him that excuse, he also admitted that his father would be insatiable, and that the therapist was acting to protect the therapy. After the interpretations, he understood that only he could confront his father. The next session he reported in proud detail how he eloquently argued his case to his father and won. The therapist’s protection of the patient’s privacy was crucial to working on the resistance transference and continued personal growth in the patient.

 

5) Concern for Others’ Welfare. In addition to stating that psychologists contribute to the welfare of others, this principle states that we should be careful that we do not use our position of influence to do harm during or after a professional relationship. Again, if the transference is protected, the patient will be protected.

Example: A grateful patient offers a favorable business deal to his former therapist. When the patient later returns to therapy, the patient uses his knowledge of the therapist and his generosity as a resistance to a therapeutic relationship. The acceptance of the gift was not for the patient’s welfare, and interfered with the symbolic relationship that needed to be preserved.

6) Social Responsibility. “Psychologists are not guided solely by a desire for monetary remuneration.” That is to say that the goal of our work cannot be to make money like most other people. As therapists we are healers and helpers. We are expected to contribute our knowledge and insights to help individuals and social policy. APA and state organizations frequently get involved with social issues which do not benefit psychologists, but serve to help individuals and society. Finally, principle 6 states, “They are encouraged to contribute a portion of their professional time for little or no personal advantage.” The setting and the collection of fees has important transference implications, which should always be considered.

Example: A graduate student with little income negotiates a reduced fee with his therapist. Both are comfortable with the arrangement, and it does not present a significant problem in the therapy.

Example: A woman is seen for a consult. She is very paranoid and presents herself as the constant innocent suffering victim. Although she works full time as a nurse, she claims she has no money for therapy
other than what insurance will reimburse. She seductively suggests that the therapist bill the insurance company for more than his usual fee, and accept their payment as full fee. By this arrangement the therapist and she would then be able to meet without any money changing hands, encouraging the fantasy of a seductive and entitled relationship. The therapeutic relationship was to be devalued as not worth her own money. It is clear that she could afford the fee but felt entitled to free treatment. If the therapist had agreed to see her under these arrangements, the therapy would have soon ended with the patient feeling cheated for one reason or other.

A reduced fee or not making the patient responsible for payment can lead to a seductive non-therapeutic relationship. A devious fee arrangement means that the therapist is not trustworthy. The therapist must be ever mindful of what this means in terms of transference/countertransference, or else no favor is done.

 

Preventive Measures

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Psychologists must remain aware of the current ethics, standards, regulations and laws affecting their practice. APA’s Professional Liability and Risk Management (Bennett, Bryant, VandenBos and Greenwood, 1990) is an excellent guide. In addition, state psychological associations may also publish information relevant to their state’s particular laws and regulations. “Pennsylvania Law and Psychology” by Knapp and VandeCreek (1990) could serve as a model for other state psychology associations.
There has been a movement afoot to concretize informed consent whereby a new patient is given in writing the therapist’s disclosure and patient responsibilities. A recent example of a psychologist’s disclosure and client responsibilities agreement by Bonnie Strickland was published in the Independent Practitioner (1991) in which she provides the patient with a brief description of her professional background, a description of the type of therapy, limits of confidentiality the fee for the services and length of sessions, policy for missed appointments and cancellations, phone calls between sessions and vacations. There is a place for the client and the therapist to sign, and it is dated.

Included in this informed consent, Dr. Strickland states “Sexual intimacy between client and therapist is never appropriate during or following a therapeutic relationship. Such behavior should be reported to the State Board of Psychologists in Boston.”
Although this is ethical, and a recommended procedure, it is anti-analytic. It is also probably harmful to the therapeutic relationship by creating distrust. It represents an example of ethics of the manifest versus ethics that account for an unconscious. Although Dr. Strickland’s disclosure and responsibilities agreement has many fine features, a statement forbidding sexual contact in the therapeutic relationship should scare most patients. It communicates an effort to control inappropriate impulses that are not expected to occur in the professional relationship by both a contract and the threat of the patient reporting the therapist to the state board. This implies that the therapist is not to be relied upon on the basis of her maturity or trustworthiness, and needs the patient to act as a control. It also identifies the therapist as one who will work on a superficial level, who is unaware of the many levels of communication. The transference is not protected, and a great deal is revealed to the patient about the therapist’s reliance on control versus interpretation and insight.

There is not just a danger of professionals acting out in a way which hurts the profession and hurts patients, but also of professionals using ethics in such a way that it communicates to patients that as long as everything is written down and signed, subtle seductions, superficiality, major empathic failures, indignities and incompetence will not occur. Although I recommend clear, explicit communication of all ground rules of therapy, cancellation and vacation policy, fees, length of the sessions, etc., at the beginning of therapy, it is important to consider the protection of the transference as an underlying principle.

In summary, I recommend that 1) all psychotherapists, regardless of the type of therapy they practice, be educated in the psychodynamics of the therapeutic relationship, with special emphasis on transference and countertransference; 2) personal insight therapy be required of all psychotherapists, so that they are aware of their own issues, conflicts and defenses in their work with others, and 3) periodic mental status consults be recommended for all psychotherapists.

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REFERENCES

 

American Psychological Association (1991). Ethical principles revision draft. The Monitor. June. Washington, D.C.
Bennett, B.E., Bryant, B.K., VandenBos, G.R. and Greenwood, A. (1990). Professional Liability and Risk Management. Washington, D.C.: American Psychological Association.
Freud, S. (1912). Recommendations to physicians practising psychoanalysis. Standard Edition. 12: 111-120.
Freud, S. (1913). On beginning the treatment (further recommendations on the technique of psychoanalysis). Standard Edition. 12: 121-144.
Knapp, S. and VanderCreek, I,. (1990). Pennsylvania law and psychology. Harrisburg, PA: Pennsylvania Psychological Association.
Langs, R. (1976). The Therapeutic Interaction, Volume I and Il. New York, New York: Jason Aronson, Inc

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