Physical Contact Between Psychotherapist and Patient: Ethical, legal, and Psychoanalytical Considerations

February 27, 2008

It can now be safely assumed, or at least hopefully assumed. that psychologists know by now that sexual encounters with patients are unethical, illegal. and severely damaging to patients. But in the more subtle area of other types of physical touch, ethical. legal. and clinical guidelines become less clear. Is that hug at the end of the session okay? Is it ethical, and clinically wise, to gently pat your patients on the back as they exit the consulting room?

The APA Ethics Code, and the psychology licensing law, address blunt concerns like sexual relations with current or former patients which, obviously, are completely prohibited. Sexual harassment is expressly forbidden. The appropriateness of less sexual forms of touch, such as hugging or patting backs, is only addressed indirectly. Within Section One, for example, psychologists are cautioned to avoid harm, to avoid misusing their influence, and to monitor their own personal problems and conflicts. Fairly intimate physical contact like a hug could occur as a result of a lapse in one of these ethical guidelines. For example, a psychologist might initiate a hug because of their own excessive loneliness or some such. This could be an ethical violation, since it could be a result of “their own personal problems…”

The psychology licensing law derives some of its rules directly from the Ethics Code and is therefore similarly vague regarding more subtle forms of physical touch. Other areas of the law, for example the Civil Code, allow for causes of action against psychotherapists who engage in sexual relations with patients. The law is silent regarding specific remedies in cases where patients are harmed or injured by other types of gentle physical contact.

Turning to the clinical realm, and using psychoanalytic theory as a guide, the overriding area of concern when considering physical touch is its potentially negative impact on the psychoanalytic frame. This ambiguously defined phenomenon may be viewed, in brief, as the envelope or membrane around the psychotherapist- patient relationship that renders the relationship therapeutic. It may include such pragmatic considerations as the fee and the amount of time spent providing each treatment session. More subtly. it includes such things as limitations in self-disclosure, allowing for the transferential relationship to unfold, and abstaining from acting out feelings which are, instead, to be discussed and understood. Obviously some place exists for physical touch, i.e, restraining a patient who has an epileptic seizure, or hugging a patient who is leaving treatment after many months or years of intensive psychotherapy, but any physical touch that even begins to border toward the sexual. or is inappropriate in some other fashion, risks harming the psychotherapeutic enterprise by destroying this psychotherapeutic frame. Although they all overlap with one another, and share in common a destruction of the psychotherapeutic frame, nine distinct problems can occur whenever physical touch is introduced into the psychotherapeutic relationship.

First, though most psychoanalytic treatments encourage regression, and this is indeed part of the transformational process, it is important that the crucible in which this regression occurs is closely controlled. Physical touch risks eliciting what Michael Balint has termed malignant regression. He wrote of such patients, “as soon as one of their primitive wishes or needs was satisfied, it was replaced by a new wish or a craving, equally demanding and urgent.” (p. 138). While psychotherapists must continually be distinguishing between benign and malignant types of regression, once touch is introduced, it may become impossible to differentiate between them.

Second, physical touch risks rendering the transference concrete. What distinguishes psychoanalytic psychotherapy from any other type of treatment intervention is the emphasis on having the transference relationship to study as a vehicle for psychological change. For example, once psychotherapists interpret patients romantic feelings as real, and act upon them in some way, then the fantasized, projected relationship that can be interpreted and understood vanishes.

Third, and similar to the concretizing transference issue, the countertransference can be concretized. Psychotherapists may interpret their romantic feelings for patients as real rather than a reaction to something symbolic occurring which may guide the psychotherapy in a helpful fashion. Sandor Ferenczi, an early and innovative follower of Freud, learned the hazards of this after experimenting with what he called “active therapy.” He attempted to create a directly loving environment for his patients, believing it would heal by providing love they had never had. Toward the end of his life, he regretted the approach, finding that the patients had developed an intense dependency rather than experiencing much improvement.

Fourth, any type touch by psychotherapists may be construed as incestuous. One of the most harmful aspects of actual incest is the fact that the parental figure, as a idealized symbol of a safe and secure world, is destroyed by the incestuous act. Most patients, even if only on a deeply unconscious level, want their psychotherapists to have a certain authority that will be utilized to help them. Once psychotherapists begin acting like lovers, or even too affectionate parents, their appropriate authority disappears.

Fifth, physical touch may severely harm sexually abused patients who already have a great deal of confusion regarding physical touch, love, and appropriate boundaries. Even such overtly benign activities as occasional hugs by psychotherapists may be highly traumatic to patients with a history of sexual abuse.

Sixth, physical affection may offer gratification that appropriate psychotherapy should not provide. Effective psychotherapy strives to empower patients to manage their own lives more effectively. If lonely patients, yearning for physical touch, can count on haVing regular hugs and other forms of physical contact with their treating psychotherapists, this may actually impede their ability to learn how to obtain much-needed contacts in their own lives.

Seventh, physical touch risks restricting the range of affect available for expression, and exploration, within the psychotherapeutic process. Patients who undergo psychotherapy in an appropriate frame, and with appropriate boundaries, must come to terms with a variety of loss experiences. As Robert Stolorow remarked in a recent lecture, psychotherapists spend their entire day telling patients who have become highly attached to them to leave their offices at the end of 45 or 50 minutes. Patients should feel rejected by that experience! Sessions that end in an affectionate hug may deprive patients of the ability to experience such emotion, express it, and ultimately work through it.

Eighth, physical touch may well lead to what Glen Gabbard has called a “slippery slope” toward other, more severe boundary violations. In actual cases of sexual misconduct by psychotherapists, usually there have been other, more subtle boundary violations such as sessions lasting overtime, or sessions held late at night, that often predict .a sexual violation. Excessive physical touch could certainly be construed as yet another predictor of sexual misconduct by psychotherapists.

Ninth and last, inappropriate physical touching most likely reflects psychotherapists’ impaired ability to tolerate pain — a skill that psychotherapists require to be effective with their patients. It is of course the most natural thing in the world to want to hold or otherwise physically comfort an individual in your physical presence who is experiencing pain in some sense. However, and again in the interest of empowering patients, they should be assisted in developing their own ways of handling pain rather than becoming excessively dependent on their treating psychotherapists.

Most likely, physical contact at the very least risks adversely effecting the psychotherapeutic relationship in any number of ways, but these nine at least provide a fairly comprehensive overview of the primary ways such touching may be harmful. In brief, physical touch risks destroying the frame in which the transformational process unfolds. And once the frame deteriorates, psychotherapy cannot occur.

References
Balint, M. (1968). The Basic Fault. Northwest University Press. Evanston, Illinois.

Published as:
Karbelnig, A. (2000). Physical contact between psychotherapist and patient: Ethical, legal, and psychoanalytical considerations. The California Psychologist, 33(6), 32-34.

(Dr. Karbelnig, a past Member of the CPA Board of Directors and current Chair of the Ethics Committee of the San Gabriel Valley Psychological Association, practices psychoanalytic psychotherapy and forensic psychology in South Pasadena, California.)

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