Ethical Dilemmas in Therapy

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Ethical standards in therapy are, unfortunately, not entirely helpful. In addition to “believe that what you’re doing is helpful,” it mostly boils down to “don’t have sex with the customers.” This is good advice, but it hardly covers the various ethical dilemmas in which therapists sooner or later find themselves.

And sadly, the ethics part of therapy training is very thin.

So here are some ethical dilemmas that therapists (credentialed or not, skillful or not) face, which almost no one talks about.

~ When therapy with one partner can threaten their relationship

Some couples can only survive if one or both partners grow. (In that case, a great therapist can be invaluable). In some couples, one person needs to change more than the other. Sometimes that person wants to, sometimes they don’t.

Some relationships are unhealthy but stable. For example, when a conflict-avoidant person marries a controlling, aggressive person, this pair of unhappy people can go on forever. The controlling person generally doesn’t come into therapy, but the passive one often does—with unreliable erections, low desire, or inhibited orgasm.

When this passive person comes in for a supposedly sexual problem, we talk about their anxiety, powerlessness, and sense of emotional isolation. That inevitably leads to discussing their relationship, integrity, self-esteem—and resentment. The passive person may then realize what they’ve given up, decide that’s no longer acceptable, and start asserting themselves—which often destabilizes the relationship.

I can usually see this coming a mile away. So should I warn the new customer in the first or second session? Should I tell them to warn their partner? Should I discourage or even refuse treatment, knowing the pain they’ll be going through—and possibly losing their marriage in the bargain?

~ When religion (or other cultural value) takes certain interventions off the table.

Like all experienced clinicians, sex therapists have a set of tools—interventions—that we typically use to address a given issue. Some of these are frowned on, misunderstood, or even banned by a patient’s religious, cultural, or family values. These can include:

Sex toys
Talking honestly about one’s experience
Teaching a partner about one’s body
Refusing painful sex
Refusing unwanted conception

When I’m told I can’t use my best tools, what should I do? Send the patient to another therapist who will tell them the same unacceptable thing? Send them to a therapist who’s willing to work under restrictions—which I’m sure won’t work? Continue seeing the patient or couple, working with one hand tied behind my back, getting inadequate results?

~ When another involved therapist is sex-negative, gender-stereotyping, or damaging

Whether I like it or not, there’s often another therapist involved in my cases: I’m seeing the couple and there’s one or two individual therapists, or I’m seeing an individual who’s in couples counseling.

Since most therapists get no training in sexuality, and some therapists are, like some people, uncomfortable with sex, this other therapist is sometimes more of an obstacle than a help. For example, they’ll use stereotypes (“men cheat way more often than women”); or be judgmental (“why would a mature man look at porn?”); or be simply wrong (“anyone into BDSM is obviously emotionally damaged”).

What do I do then? I can’t simply say “your other therapist is wrong.” Saying “you should stop seeing your other therapist” may be smart advice, but almost no one will take it. And that’s not a reputation I want to get, anyway. I end up calling the other therapist way more often than is typical among my colleagues. Sometimes I’m able to share a different perspective, or set of facts. Sometimes the call just confirms my worst fears about an immovable obstacle.

~ When patients want me to recommend a sex worker, erotic website, or porn

Every week I recommend attorneys, physicians, physical therapists, and psychologists to my patients. I’m proud of my professional network.

But when people ask “how do I find a prostitute,” or they want to know where the “safe” massage parlors are, I simply say “Because those things are illegal, I can’t recommend anything like that.”

Too many sex therapists are only too happy to recommend this or that sex worker—in my opinion, without considering possible consequences. For example, if a guy goes to a strip club I’ve mentioned, and his wife finds out and gets angry, she won’t be eager for him to continue seeing me.

Adult porn, of course, is legal, but I don’t recommend any specific porn because patients will inevitably read something into whatever I recommend: they’ll think it’s a clue about what I’m into, or what I think they’re into, or should be into. While talking about porn (which I do with patients every week) can be quite valuable, its complicated enough without that extra layer.

~ When a couple wants help conceiving—for problematic reasons

At least once a month a couple comes in wanting to fix a sexual problem because they want to conceive. Is the reason they want to conceive any of my business?

What if they don’t really want a baby, but they’re being pressured by their parents? Or it’s culturally normative back in India or China, where they’ll never live again? Or their younger sibling can’t marry until my couple has their first child?

Do I go ahead and help these various couples conceive by enhancing their sexual function, or do I hesitate? What if I genuinely believe that a marriage is so precarious that another kid will destroy it? What if a couple believes “the thing that will fix our ugly marriage is a baby”—which almost never works?

Life-altering decisions like these demand I think about where my integrity lies, and what my call to service is—which I end up thinking about every week.
The ethics training therapists typically get is “don’t sleep with the customers,” “remember, not everyone is heterosexual,” and “get everyone’s pronouns right.” That’s hardly enough when addressing complex real-world circumstances, especially if they involve sexuality.

The real world, and the customers it sends us, is complicated and nuanced. If we manage to get through a month of practice and to genuinely do no harm, it’s a good month.
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