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Tuesday, August 25, 2009

Treatment Tuesday - Doctor/Patient Relationships

We've got a great question on the therapeutic table today, people! The writer, who wishes to remain anonymous, wrote in with a blurb about her book. Molly* sets her sights on hot young psychiatrist Dr. Wade Williams.* She makes about four trips to his office for “evaluation,” even though she’s feigning her symptoms. The author has lots in store for Molly and Wade, but the gist of her dilemma is that Dr. Williams stops his evaluation of Molly and then enters into a relationship with her. She’s afraid the reader might think Dr. Williams is being unethical, but in the final scene (**SPOILER**) he informs Molly that he never took her on as a patient.

* Names have been changed to protect the fictional.

Here’s the real question:

It was brought to my attention it is against the law for a doctor to date a patient for two years or something to that effect, but I took artistic license and played the story out the way I wanted to. Is this a believable plot line (in the realm of romantic comedy fiction)? Or am I staring down the barrel of some serious issues here?

What a packed question! Let’s try to unravel it today.

First off, whoever brought it to your attention that it’s against the law for a doctor to date a patient was absolutely right, mostly, so I’d say you are staring down a very ominous barrel of serious issues. But there is a lot of variation between counseling organizations as to how many years have to lapse before a relationship can be entered in, if ever.

Since Dr. Williams is a psychiatrist, his code of ethics would fall under the American Psychiatric Association (APA), which I knew little about. However, upon a Google search, I came to understand the APA essentially uses the ethical codes of the American Medical Association (AMA). Since a psychiatrist IS a medical doctor, this makes sense. The APA does have an annotated version of the ethical code of the AMA that specifically applies to psychiatrists, yet I couldn’t find anything in this code about sex with a patient (only sex between a faculty member/student and a trainer/supervisee).

So then I reverted back to the AMA’s website. In Opinion 8:14, found here, it reads At a minimum, a physician’s ethical duties include terminating the physician-patient relationship before initiating a dating, romantic, or sexual relationship with a patient.” It sounds like Dr. Will

iams does this, at any rate. But honestly, this sounds like its more for general practitioners or surgeons or something, not psychiatrist doctors seeing patients in a therapeutic relationship. Let's face it, that's way different from a doctor doing a knee replacement or something.

As a therapist, this “opinion” makes me cringe. I hold to the code of ethics of the American Association of Marriage and Family Therapists (and additionally to the American Association of Christian Counselors). Our code read much more substantially:

1.5 Sexual intimacy with former clients is likely to be harmful and is therefore prohibited for two years following the termination of therapy or last professional contact. In an effort to avoid exploiting the trust and dependency of clients, marriage and family therapists should not engage in sexual intimacy with former clients after the two years following termination or last professional contact. Should therapists engage in sexual intimacy with former clients following two years after termination or last professional contact, the burden shifts to the therapist to demonstrate that there has been no exploitation or injury to the former client or to the client’s immediate family.

See the difference? Of course, what’s really on the table are sexual relationships, which Dr. Williams will not be having with Molly at any rate. But dating relationships still fall under a gray area…because in most of the world, that leads to sexual relationships (in or out of the marital covenant).

The other area your book brings to light is what constitutes a patient. Does an evaluation/assessment count? What if the client wants to meet the therapist to determine if she would mesh well with his treatment modalities?

To answer this question, you’re going to have to really think about these four “evaluation” sessions. I’m not sure what all he’s evaluating that would take that long. It sounds like some of the assessment sessions might be more. Typically, for therapists to get paid by insurance parties, you have to have the assessment done and at least a temporary initial diagnosis to submit to the insurance company. You can continue to “evaluate” if you feel another session might be needed to really nail the diagnosis, but most good therapists/psychologists/psychiatrists already have a very good idea after one hour, I promise.

So what’s really going on in those sessions? How much evaluation does she really need? And what’s taking him so long? I guess what I’m trying to say is that four sessions would likely constitute a therapeutic relationship of some sort. One could assume a session happened every consecutive week and that they were going deeper and deeper into her personal history, problems and reason for coming in the first place. If I were reading your book and read that they’d had four sessions, I would think he was being unethical, then, when he enters into a dating relationship with her. This would put me off so much I might be tempted to close the book, but I’m not the average reader in this area.

You’re doing what you need to do, though, by researching. You want your book to fall into the feasible plot realm for a psychiatrist, and from what I see, you have Dr. Williams dangerously skirting around the line of unethical behavior. Technically, according to the AMA, if he ends the medical relationship, he’s cleared to date her. Morally, though, this might not sit right with a lot of the population of readers. They will resonate with Molly’s sister and best friend, which you’re not going to want!

So now that I’ve possibly ruined your plot premise with my assessment, I’d like to maybe give some alternatives. If possible, decrease the number of sessions they actually have. It will be far more ethical for him to have one session—two, tops—and then not take her on as a patient and date her. I realize your plot twist of him revealing to her he never took her on as a patient is major to the end of the book. Is there anyway for that to come out earlier? Like before they actually go on a date? Then the reader’s mind would be at rest for the remainder of your story. Maybe there would be some other great reveal at the why Dr. Williams isn't with his ex or something.

Another option is for Dr. Williams to perhaps be in a practice where there are more than just one psychiatrist working. Perhaps Molly could be seen by one of Dr. William’s associates and therefore totally bring their romance out of the sticky realm of one of his own patients.

I’m not sure this helps much. I feel like this is the first assessment I’ve done that wasn’t all that positive! Please feel free to email me if you have some other questions, or just leave them in the comment section. Good luck with your writing! Other than the ethical dilemma, it sounds like a superb romantic comedy!

This service is for fictional characters only, so any resemblance to real life examples is entirely coincidental. Any other fictional character assessment questions can be directed to

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Jessica Nelson said...

Definitely sounds like a tricky situation to me. I still remember that movie with Nick Nolte and Barbara Streisand. Even as a teen I thought it really weird that she would sleep with him.

Jeannie Campbell, LMFT said...

jessica - hollywood definitely doesn't portray therapists in an ethical light. the movie Prime, while not a sexual relationship, is probably one of the worst examples of how NOT to do something.

Jill Kemerer said...

Great post! If any of my characters end up being therapists, I'll definitely keep this in mind.

Stephanie Faris said...

I work for the department that licenses psychiatrists (and all other medical professionals) here in TN. It's my responsibility to record all the hearings where they revoke licenses of therapists (and doctors, etc.) who have been naughty. This is the number one problem we have with therapists, actually. And I will say, the ONLY WAY the State would know about it to revoke your license is if somebody complained. The problem would then be the reader's perception of the therapist in light of this.

As a reader, if the therapist ended his counseling as soon as he had feelings for ethical reasons, I think I'd still be following along, thinking highly of him. If I were writing this, I'd use this whole thing as conflict in the book. The fact that he risks losing his license and his practice if he loves her makes for one of those gut-wrenching sort of things that drives readers crazy. If it's not too late, I'd really work that in...just in my humble opinion.

Tana said...

Great post Jeannie! I'm always amazed at how much hard work you put into your evaluations. I suppose the number of treatment sessions should be cut back and I like the idea of the MC perhaps seeing another collegue to defuse the weirdness that can come from a situation like that. Lot's to think about indeed.

Katie Ganshert said...

This was a very fun my creative juices going. Have you ever watched The Waitress with Keri Russell? She enters into an affair with her doctor. It's completely not a moral movie, but I love Keri Russell, so I liked it. :)

Jeannie Campbell, LMFT said...

katie - i LOVE keri russell! own all the felicity DVDs. :)

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Both comments and questions are welcome. I hope you enjoyed your time on the couch today.