Abstract
Paul Fitzgerald, The Clarke Institute of Psychiatry, Toronto, and Whitby Mental Health Centre, Whitby, Ontario, Canada:
I was interested to read the excellent and creatively titled paper by Christopher Ryan in a recent edition of the Journal [1]. I was a little surprised, however, at the conclusion that ‘psychiatrists and trainees currently in supervision would be at liberty to conclude their supervisory relationship and then to embark upon a sexual relationship immediately’. While in general I agree with the arguments presented against a prohibition in these circumstances, I believe that Ryan excluded an important argument that he has previously raised in the analogous example of therapist-patient sexual relationships post therapy termination [2]. The argument was made in an elegant way in the original paper and I would recommend reading it to those who have not.
The argument states that a sexual relationship between therapist and patient is inappropriate following the termination of therapy because of the implications for future patients entering therapy with the same and other therapists based upon notions of confidentiality. In particular, the knowledge that a future sexual relationship is possible with the therapist may alter the way in which the patient interacts with the therapist and the material revealed in therapy. To quote: ‘Patients will not tell their doctors everything if they believe that their doctor may become their lover’ [2]. It is then argued that the occurrence of post-termination sexual contact will ‘erode the community's confidence in the safety of self-disclosure in therapy’.
As stated by Ryan, ‘Most of the arguments raised to support the prohibition of such sexual relationships (those between supervisor and trainee) are similar to those often used to show that patient-therapist sexual contact is unethical’ [1]. I believe that this applies to the argument presented. It is quite reasonable to presume that, if a trainee or supervisor entering a supervisory relationship considers that the development of a future sexual relationship is possible or desirable, this may effect the quality of the supervision. For example, a supervisor may be reluctant to be critical of the trainee's behaviour or the trainee to reveal difficulties or mistakes. This may lead to harm to patients under the care of the trainee both immediately through inadequate supervision of ongoing treatment as well as in the future through the development of poor therapeutic skills. In addition, the occurrence and professional acceptance of post-supervision sexual relationships is likely to erode the confidence of the ‘community of trainees’ in the safety of disclosure in the relationship with a supervisor.
Obviously, there are differences in the nature of therapeutic and supervisorial relationships. Confidentiality and the ability of both parties to be open and honest, however, are crucial in both and I believe that the analogy of this argument appears to hold well.
The bottom line is the question as to whether the arguments for prohibition are sufficient to outweigh the assumption of the right to autonomy of the individuals as identified by Ryan. I believe that the argument presented here is a strong and valid one against supervisor-trainee sexual relationships following the termination of supervision. Additionally, it is appropriate for the College to carefully consider recommendations that would council against the appropriateness of these relationships and to raise debate as to the possible inclusion of the issue within the college code of ethics. A particular issue that requires careful thought and debate concerns whether there is an appropriate time interval following which post-supervision sexual relationships would be considered unproblematic. The time at which a trainee completes training in psychiatry may be a suitable point for a cut-off where a sexual relationship that started after this time could be considered as appropriate and between equals.