Posttermination Boundary Issues

To the Editor: While refraining from calling for a repeal of APA’s ethical proscription against sex with former patients, Carl P. Malmquist, M.D., M.S., and Malkah T. Notman, M.D. (1), argued in their article on posttermination boundary issues that legal misapplications of imprecise and unproven concepts of transference and countertransference have created an unfair legal liability for therapists who enter posttermination sexual liaisons with their patients. Although their article focused primarily on the legal aspects of this issue, their failure to reference literature describing the destructiveness of posttermination sexual boundary violations (2–4) gave readers a one-sided presentation regarding the reasons that courts and medical licensing boards generally take such a harsh view toward mental health professionals who violate the posttermination standard. Whether the issue of misuse of transference is cited in a final legal order or not, the bottom-line responsibility of courts and licensing boards is to protect the public safety.

From years of study about the problem of human error (5), it has become clear that expert performance of potentially dangerous tasks becomes subject to numerous failure points on the basis of lapses in skill, improper adherence to empirically derived safety guidelines, or lack of an adequate knowledge base upon which to initiate crucial interventions. Skills-based performance, in particular, is formed through repetitive training that results in overlearned behavior and cognitions that enable experts to enter an “auto-pilot” mode, during which they undertake complex cognitive and behavioral operations in a smooth and rapid fashion, without having to rely on more labor-intensive and inefficient conscious mentation. Such automatic cognition or action relies primarily on material encoded in the procedural, as opposed to the episodic, memory system (6).

Psychiatrists who permit themselves to justify that a sexual relationship with a particular patient after termination would ever be acceptable are likely to engage in preparatory planning to “groom” a patient for a future liaison. Since psychiatric practice is fraught with many opportunities for committing serious error even before a so-called “termination” ever occurs, a psychiatrist’s self-granted permission for posttermination sex exposes the patient to biased and dangerous treatment. Harboring the idea during treatment to engage in a romance with a patient at some future time after treatment has ended causes the psychiatrist to consciously or unconsciously be motivated to avoid interventions during the treatment that might serve to “pour cold water” on the eagerly expected posttermination liaison. Such inappropriate, goal-directed bias interrupts vital skills-based procedural memories acquired in training through repetitive drilling and proper role modeling—namely, that lust, need for control, or inappropriate anger must never be allowed to interfere with the physician’s prime directive of acting primarily for the patient’s well-being. This ingrained “memory” does not occur simply as an intellectual piece of knowledge to be tucked away in books or journal articles. Of more importance, it is a fundamental attitude that should assume the function of a learned but exceedingly valuable character trait, imbued through years of anguished repetition experienced while caring for vulnerable patients (7).

In the debate over posttermination sexual relationships, arguing over the scientific validity of the constructs of transference and countertransference or whether the posttermination prohibition should apply to psychiatrists who claim not to rely on these theories in their treatment methods can be seen as a form of sophistry that is dangerously divorced from clinical reality. From the standpoint of psychiatry’s quest to reduce medical error, the transference and countertransference constructs serve a useful purpose, mainly because they conveniently summarize a mode of thinking in which the psychiatrist closely attends to the subliminal, automatic, stereotypical behaviors and cognitions (i.e., procedural memories) that arise during the interpersonal process between the patient and psychiatrist. Transference and countertransference can be seen as convenient ways of labeling the mixture of moment-to-moment overt and covert cognitive and behavioral processes that occur between psychiatrist and patient. Anything that tends to weaken serious attention to these processes increases the risk for medical error. These constructs help to organize and summarize the cognitive and behavioral traps a psychiatrist can get into with patients—something that is as applicable to cognitive behavior treatment as to psychoanalysis. Devaluing attentiveness to transference and countertransference processes invites a “dumbing-down” of the practice of psychiatry and is a ticket for disaster, because it permissively encourages clinicians to harbor the illusion that they are immune to bad judgment or to being blind-sided.