Boundary violations and attachment

Sarkar (2009) argues that transference is the crucial ethical obstacle to sexual relationships between psychiatrists, psychotherapists and patients, present and past. However, as he rightly points out, transference and power inequalities are ubiquitous. In the invited commentary, Sheather (2009) highlights the purpose of the doctor–patient relationship to allow the divulgence of intimate details required for treatment, and that it is the intrinsic emotional vulnerability of psychiatric patients that underpins the prohibition on relationships with them (although Sarkar has already argued that this may be patronising and stigmatising and in any case emotional vulnerability per se is no obstacle to relationships in other contexts).

Attachment theory describes how mammals are instinctually driven, via the attachment system of behaviours, to seek proximity to a caregiver or ‘secure base’, who provides the security that is a precondition for exploration (Ma 2006). Psychotherapeutic encounters differ from other medical encounters in the degree to which clinicians set out purposefully to cultivate an attachment relationship with patients (Ma 2007). As Bowlby (1988) writes: the first task of psychotherapy is to ‘provide the patient with a secure base from which he can explore the various unhappy and painful aspects of his life’. It is the existence of this attachment relationship, deliberately pursued as a psychotherapeutic means and end, beyond either transference or vulnerability, which sets apart the relationship between psychiatrist or psychotherapist and patient. A romantic relationship after a psychotherapeutic relationship inevitably exploits the (psychotherapeutic) attachment relationship.