How Wary Are Psychotherapists About Intimate and Informal Behavior?

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Therapists are expected to behave ethically toward clients and avoid behavior that may harm or exploit a client, such as sexual relationships.

Psychotherapists may tend to be restrictive in their attitude toward intimate and informal behavior (IIB) in the context of psychotherapeutic relationships with their clients, according to a published report in Psychological Medicine.

Therapists are expected to behave ethically with clients and avoid behavior that may harm or exploit a client, such as sexual relationships. However, current research on other IIBs are scarce, especially those that are not explicitly mentioned in ethical codes.

Investigators conducted a cross-sectional study from November 2016 to June 2018, offering a self-administered questionnaire to 786 Flemish Dutch-speaking therapists.  The survey aimed to describe opinions about the acceptability of IIB, identify specific attitude groups of therapists, and find correlations between attitude groups. To explore the attitude of the therapists, the researchers assessed opinions about the general acceptability of 11 statements on a 4-point scale, ranging from completely unacceptable to completely acceptable. Additionally, they investigated the occurrence of 5 intimate and informal events that happened in the previous 12 months.

The therapists could be divided into 3 groups: rather restrictive, socially permissive, and sexually permissive. About half of the therapists were rather restrictive in their attitudes, whereas nearly 33% of respondents were considered rather socially permissive and 20% rather sexually permissive.

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Nearly all therapists agreed that flirting with a friendly client (97.2%), accepting a Facebook friend request (98.45%), and letting the client help with a private task at the therapist’s home (98.6%) were unacceptable.  Conversely, nearly a third found it acceptable to start a romantic relationship with former clients 2 years after the end of therapy. Therapists in the middle-age group (40-49 years; 57.7%) mainly belonged in the rather restrictive group compared with the oldest group (60 years and above; 46.8%) or youngest group (20-39 years; 37.3%).

Those categorized as sexually permissive were predominantly male, not heterosexual, and evenly distributed across training disciplines, whereas being socially permissive or restrictive were primarily related to psychotherapy training—behavioral and psychoanalytic, respectively. Compared to the restrictive and socially permissive therapists, the sexually permissive therapists more often found a client sexually attractive (P <.001) and fantasized about a romantic relationship with a client (P =.010), although they did not start sexual relationships with greater frequency (P =.478).

Overall, these findings demonstrate that therapists are generally rather cautious and have a high sense of morality toward unacceptable behavior. Limitations of the study include potential response bias, as the researchers could not rule out that socially desirable answers were given.

“Maybe it is not so surprising that therapists left some ‘negotiable space’ for acceptability, because of their deep awareness of the unique complexity of each situation where they have to determine how to flesh out their therapeutic relationship with a client,” the researchers concluded.


Vesentini L, Overmeire RV, Matthys F, Wachter DR, Puyenbroeck HV, Bilsen J. Psychotherapists’ attitudes to intimate and informal behavior towards clients. Psychological Medicine. 2020;1-7.