When Doctors and Patients Become Involved : Ethics: Sexual contact between therapists and patients is not new. But now it is the subject of a growing number of malpractice cases.

Psychiatrists who have sex with their patients tend to be men over 40 who are in practice by themselves and are depressed, unhappily married, burned out professionally and abusing drugs or alcohol.

Their victims are most likely younger, attractive women who were sexually or physically abused as children and sought therapy because of depression over a broken relationship. They may have a diagnosis of dependent or borderline personality disorder--a condition characterized by impulsiveness and self-dramatizing behavior.

In most malpractice cases where sexual contact occurs, according to Robert I. Simon, a clinical professor of psychiatry at Georgetown University School of Medicine, involvement proceeds gradually as the boundaries of neutrality and abstinence from self-gratification that are cornerstones of treatment are eroded. “It’s incremental, an aggregation of things,” Simon told psychiatrists attending the annual meeting of the American Academy of Psychiatry and the Law.

“It’s going on a first-name basis, it’s having social conversations with a patient, it’s ending the session with a hug or a kiss, it’s shifting therapy to the end of the day.”

Various surveys show that between 6% and 15% of therapists--most of them men--admit to having had sex with patients, typically women, who sustain enduring emotional damage from the relationship.

Although the problem has received increased attention in recent years and is the subject of a growing number of malpractice cases, sexual contact between doctors and patients is hardly new. It has long been understood to be a violation of the Hippocratic Oath. And the problem is not confined to psychiatrists.

This fall, a District of Columbia Superior Court judge awarded $1 million in damages in a divorce case to Frederica Lehrman Carmichael, who said her husband--a psychologist whom she met when she consulted him for problems in her second marriage--committed malpractice by having sex with her while she was a patient.

The judge found that although psychologist Douglass Carmichael married her in 1983, he continued to treat her until 1986, thereby committing malpractice. In his ruling the judge wrote that the woman, an heiress to the Giant Food fortune, saw her psychologist-husband as a “savior from all of the things that were haunting her life,” while he regarded her as the answer to his pressing financial problems.

The American Psychological Assn. and the American Psychiatric Assn. condemn sexual involvement with patients as unethical and regard it as grounds for expulsion. A growing number of states are outlawing such contact, even if consensual. In Minnesota and Wisconsin, therapists who have sex with a patient can be criminally prosecuted.

Juries also take an extraordinarily dim view of such cases, presuming that a therapist who has sex with a patient is exploiting the trust and emotional fragility of someone who has confided her most intimate secrets in the hope of getting help.

Last year, an Oregon jury ordered a Portland psychiatrist to pay $1.9 million to a woman with whom he frequently had sex--and whom he billed for each visit--during a 12-year period.

In his presentation Simon, who has written extensively on the subject, outlined the most common scenarios in which therapists get into trouble.

More spectacular cases may involve the use of drugs to sedate patients or Svengali-like manipulation of patients who perform nonsexual and sexual services. Less malignant behavior, Simon said, may involve “role trading.”

He cited the case of a 63-year-old psychiatrist, depressed after the death of his wife, who treated a 45-year-old woman for marital problems. As treatment progressed, the tenor of therapy changed and the doctor began confiding in the patient and sometimes cried during the sessions. The patient assumed the role of comforting confidant and sought to reassure him. The two began to see each other--and sleep together--outside of the office. The therapist found that his depression lessened and initially the patient was gratified by her psychiatrist’s interest in her.

“Most of us have had to deal with our problem of being rescuers,” Simon noted, “and behind that wish to rescue someone else lies the desire to be rescued ourselves.”

Unless that issue is dealt with in the doctor’s own therapy, which usually occurs early in his career, the wish to be rescued can become a serious unresolved problem, according to Simon.

The matter of therapists’ attraction to patients, or former patients, has always been a particularly thorny one for psychiatry.

Freud propounded the abstinence principle, which states that psychiatrists should refrain from using patients to gratify their personal needs. He warned that the common experience of a patient’s falling in love with a psychiatrist “is not to be ascribed to the charms of his person.” Rather, he said, it is due to the necessary and predictable process known as transference, in which patients project their earliest and most intense feelings, usually toward a parent, onto the therapist.

The process of therapy is further complicated by the issue of counter-transference, in which the therapist projects intense personal feelings onto the patient.

Sex with a former patient is regarded in some cases with slightly less disfavor than a relationship with a current patient. The American Psychiatric Assn. says it is “almost always” considered unethical. Some states have enacted so-called “waiting periods” ranging from six months to two years, after which sex with an ex-patient is legally permissible.

Psychiatrists can best guard against improper conduct by referring to other doctors any patient who arouses unmanageable sexual feelings and by having other interests and relationships outside the office, Simon maintained. Some psychiatrists may be particularly vulnerable because they work long hours with limited personal contacts other than their patients.

“To some extent, this is an occupational hazard,” Simon said. “We shouldn’t, like some of our patients, live for our work.”