Drs. Arlene (Lu) Steinberg, Judie Alpert, and I recently co-edited a book entitled Sexual Boundary Violations in Psychotherapy: Facing Transgressions, Indiscretions, and Misconduct (2021). The topic has not received much recent attention in the professional literature, not because it no longer happens, but because it has gone into one of those voids that so often occur with various trauma topics, especially those involving interpersonal violence and aversive sexual misbehavior. We decided to write the book in the context of the numerous disclosures of sexual boundary violations (SBVs) in professional relationships that were brought to public attention due to the #MeToo Movement. Quite a number of these reports involved sexual harassment and other types of transgressions on the part of mental health and other service professionals, and we sought to bring new attention to these issues. We set out to be different from other published books on sexual boundary violations in psychotherapy (most published in the 1970s, ‘80s, and ‘90s, with a couple recently), and sought to reach both mental health and other professionals and lay audiences as well as cover topics that have previously received little or no attention. By deliberate design, victim/survivor clients are given center stage in the book, with consideration of why those who report their abuse experiences are typically treated poorly, with suspicion, or outright disbelief, and are not deemed to be credible, even today.
In this Clinician’s Corner, I’ll review some of the highlights of this contemporary overview. One of the main points that was made repeatedly by many of the chapter authors is the need for psychotherapists and other professionals to repeatedly be exposed to this topic and its often-traumatic and damaging consequences for all parties—including the therapist—as a means of maintaining awareness, increasing understanding, developing more effective and sophisticated interventions, fostering prevention, and even developing compassion for all parties. Simply discussing it once every couple of years in a mandated ethics course is not enough, especially given that many courses stress the financial and legal liability of such relationships and not the human cost. Nor do they typically or adequately address the sacred duty of professionals to protect those who have sought them out for assistance and care.
Many myths continue to surround this topic, including that its occurrence is quite rare, that it is not harmful, that it can be therapeutic/instructive/emotionally and sexually curative, that it is due to a very special relationship not understood by those on the outside, that it usually involves an older male therapist/professional and a younger female patient/client, and that its causation is due to the woman’s pathology, dependence, and seductiveness/relentless pursuit of a romantic relationship. The professional is usually absolved of responsibility, especially if he is advanced and distinguished in his career. Based on his power, status, and gender, he is usually deemed the more credible of the two parties, and often given the benefit of the doubt.
In contrast to these myths, it turns out that sexual boundary violations are not especially rare and may occur in approximately 10% of professional relationships (Gabbard, 2017), a very alarming number. Sexual boundary violations are defined as follows: When a mental health clinician or other individual, professional group, or organization agent exploits any aspect of a patient’s or client’s sexuality for their personal gain. The exploitation may involve sexualized words, pictures, behaviors, or actions, and different degrees of severity and duration. Given the power, status, and knowledge asymmetry of the therapy relationship (as well as other professional relationships), patients/clients are not able to give consent. It is always the sole responsibility of the professional to manage and maintain sexual and other boundaries.
The history of SBVs can be traced back to the original Hippocratic Oath that admonished healers to “Do no harm.” Much later, Freud himself cautioned his followers not to get sexually involved with patients, but it turned out many did not heed his warning. In fact, things went so far in the 1960s and 70s in the U.S. that therapists from the humanistic tradition and human potential movement encouraged activities, such as nude encounter groups and sex among members, between therapists and patients to drop sexual inhibitions and to develop sexual freedom and release. This trend reversed in the 80s when feminists began to study rape and heard stories of sexual misconduct in psychotherapy. Early prevalence estimates based on anonymous therapist surveys were conducted (Pope, 2011; 2017). Interestingly, early researchers who reported their findings were castigated and had their licenses threatened when they publicly reported them, as their relatively high numbers were seen as tarnishing the profession! Also, during that period, sensational lay and professional depictions in the media, and in books began to emerge, along with lawsuits, prompting attention and reforms. It was only in 1977 that the American Psychological Association included the prohibition of sex between therapists and clients in its Code of Ethics.
Today, the ethics codes of all major professions follow in this prohibition and have expanded it to apply to sexual contacts between training and treating professionals and their students/trainees/supervisees and employees, as well as family members of the patient. Boundaries between the personal and the professional are mandated in all fiduciary relationships, where the provider has a duty to protect and not exploit. State legal statutes also changed during this time to make such behavior illegal as well as unethical. Although suspension or loss of one’s professional license is the usual outcome of complaints to state licensing boards, some states have mandated jail terms and inclusion in state sex offender registries.
Sexual boundary violations can occur in a wide variety of settings (e.g., pastoral counseling, private practice, college counseling centers, community mental health centers) and now in new contexts and frontiers, using new methods (e.g., digital and social media mechanisms; Drum, & Littleton, 2014; Reamer, 2021) and with various populations (e.g., racial/cultural/ethnic and sexually diverse dyads). Reports of abuse by female therapists with both male and female patients are now on the rise (Therapist Exploitation Link Line; TELL), as are those that involve dyads of various intersectionalities. Racial, ethnic, and gender tropes are sometimes used to justify abuse.
SVBs have many variations, durations, intensities, and degrees of severity. They range from contacts that are quite situational/casual/unplanned to those that are premeditated and intentional (and sometimes involve more than one patient, either concurrently or serially).
Types of abuse, motives, and other issues can be illustrated as occurring across a continuum from less to most severe (see Table 1). On the left side are more situational, “accidental,” and unintentional/unplanned forms most associated with the naïve/lovesick/uninformed therapist who might be on a mission to rescue the patient. Although this type is more typical of novice therapists, those who are more experienced or are even senior professionals and celebrated experts are not immune to such extreme rescuing behavior that becomes sexualized. Extreme fear that a patient might suicide has been found in some cases of sexualized rescue. The right side of the continuum depicts more premeditated, intentional, and deliberate intrusions reflecting more pathology on the part of the therapist, some of whom might truly be called predators. There are many points across the spectrum, suggesting that assessment of each case needs to be considered according to its circumstance and individualized since there is no “one size fits all” scenario.
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The therapist’s general mental health and emotional well-being, relational and sexual status and satisfaction, ego strength, and ability to mentalize and self-manage are all pertinent, as are characteristics of the patient. Different therapist motivations and rationalizations (some quite elaborate) vary widely and are to be expected. Some of these issues have been discussed by Dr. Andrea Celenza, a pioneer researcher and clinician on the topic of SBVs who has an extensive history of treating therapist/offenders and patient/victims (Celenza, 2011). She provided information on common perpetrator dynamics and further discussed the possibility of rehabilitation. For those on the left and less severe side of the continuum, and when there is true remorse and the taking of personal responsibility, she believes rehabilitation is a possibility. In contrast, those on the right side are rarely able to rehabilitate and pose ongoing threats to patients. Dr. Celenza further discussed common transference and countertransference issues that may come into play and the importance of therapists seeking out colleagues or consultants/supervisors when they begin to detect attraction and romantic interests (and hopefully before any seductiveness or sexual behavior or activity takes place). Sadly, shame or hubris often get in the way of doing so. The therapist may then find themselves on what has been described as the “slippery slope” where it becomes ever more difficult to stop and to get off the slope. Although this term is in common usage and is usually understood to mean that once the process is underway it cannot be stopped, both Dr. Celenza and Dr. Jan Wolberg, a founding member of the Therapy Exploitation Link Line (TELL) a survivor-oriented website, argue that there are many points along the way for the therapist to seek out others for their perspective and assistance. Shame or hubris are not good reasons not to do so.
In terms of client/victims, there is no one type that has been identified although naïve, inexperienced, non-assertive, dependent, compliant or previously abused clients may be especially susceptible to a therapist’s advances. In recent years, it has been recognized that previously traumatized clients (especially those who experienced incest/child sexual abuse and were indoctrinated into dual relationships and groomed with misinformation about the behavior and the relationship) have special vulnerabilities that might play out in transference and reenactment dynamics. “Professional incest” can result when these reenactments occur, and the therapist’s countertransference blinds them, resulting in involvement and revictimization rather than resolution of the original trauma.
Although some SBVs start immediately at the start of treatment, it is more common for grooming of the victim to occur over a longer period, sometimes months and even years. Grooming involves a gradual erosion of proper boundaries which may start with more innocuous crossings rather than violations. These may be probes of the patient’s susceptibility to influence or capacity to resist. From there, therapists typically do things to make themselves indispensable to the patient, by offering special attention, favors, longer sessions late in the day, between-session contacts, and meetings outside of sessions. The patient, who may initially be startled or flattered by the special attention, may come to depend on it and strive to remain in the therapist’s good graces in order to continue to receive their attention/approval and to not displease them. Discussion of the therapist’s personal life may become more detailed over time, and the client may be inadvertently pulled into the role of caregiver to the caregiver. In this context, romantic fantasies and feelings may be discussed, texted, or emailed, leading eventually to touching, to fondling and increasingly sexualized behavior and verbalizations, out-of-session dates and rendezvous, and ultimately to sexual intimacies up to and including intercourse. These sometimes occur outside of the treatment setting but may also become a routine part of sessions. In another major ethical lapse involving fraud, some therapists continue to bill these sessions as psychotherapy.
The often-convoluted dynamics of such abuse typically create intense emotions (including romantic feelings, feeling in love, being the “selected one,” being approved of) in client/victims, while they may simultaneously create emotional discomfort and dissociative and posttraumatic responses. Clients describe experiences of losing their bearings, themselves, and their values over the course of the grooming, and what is referred to as gaslighting or systematic misrepresentation of the sexual contact by the therapist. Since sex occurs within the context of the treatment relationship, it creates a condition of betrayal trauma, a type of trauma that has been found to create great confusion/ambivalence for the victim, and that typically results in more severe emotional damage and betrayal blindness leading to additional vulnerability to additional victimization. The concept of betrayal trauma has expanded from the individual therapist/abuser to colleagues and others who remain bystanders or collaborators and to organizations that don’t help or intervene once a report is made and, in some cases, actively engage in cover-ups (Freyd, 2018).
Client/survivors also voiced the additional distress that ensues when their reports are accompanied by vigorous denial or aggression on the therapist’s part or by investigators and licensing board members, or when they are made to wait months or even years for investigations to be completed (during which time the therapist might be allowed to continue in practice). It is also noteworthy that while interventions are made available to accused therapists by licensing boards, they are not similarly extended to client/reporters who may then end up additionally damaged and impaired, isolated and in a limbo status. Licensing boards and law enforcement personnel should be able to make referrals to other professionals with knowledge of these issues and to those who have specialized resources.
The final section of the book is devoted to issues that can arise in subsequent therapy for the victimized client, who understandably, may approach a new therapist from a position of fear, mistrust, and extreme suspicion. Specialized knowledge of these relationships, their dynamics, and consequences are needed by those who treat these clients. Among other things, the subsequent therapist must expect strong transference and countertransference reactions on the part of the client and ambivalent feelings towards the previous therapist. They must also be prepared that the sexual relationship between the two may be continuing (whether ongoing or on an occasional basis) or may resume after a period of having stopped. The subsequent therapist therefore must be able to deal with and manage strong countertransference feelings and also strong reactions to the therapist/abuser who may well be known or who may even be a colleague. The therapist must be able to be emotionally regulated and even-handed when facing these types of challenges and may themselves benefit from outside supervision and consultation on the treatment.
Therapy for the offending therapist has similar traps and must be differentiated from clinical supervision, both of which might be mandated if rehabilitation is being considered or attempted by the licensing board. Importantly, the supervisor should not also be the therapist of the offending therapist, as these are entirely different roles, and both must have releases of information with each other and with the mandating board. Some offending therapists resist the board mandates and may lose their license to practice as a result. Prominent characteristics of therapists on the middle to the severe side of the continuum (e.g., addictions, narcissism and self-aggrandizement, entitlement, psychopathy, inability to take responsibility, and lack of empathy or remorse) and details of the sexual violations (some of which might be quite severe and “off the charts”) may preclude successful treatment and supervision and thus argue against rehabilitation and a return to clinical practice. The most egregious offenses might be the subject of criminal investigation and charges.
Most often, the transgressive relationship has ended, often badly and abruptly by the therapist who might suddenly “come to their senses” for a wide variety of reasons (e.g., recognition that the relationship is a burden and time-consuming, is not going anywhere or is destined to end badly; that the client’s mental health status is worsening or their symptoms re-emerging after their “flight into health” via the relationship; that it may become public and cause them great shame; it may put an end to one or both marriages or primary romantic partnerships; it may break up (one or both partners’) families and seriously impact children; it may affect child custody in a divorce; it may lead to loss of professional status, the means of making a living, and even loss of personal freedom due to incarceration). In fact, insensitive and sudden endings may be the reason a client decides to make a report to law enforcement or a state licensing board or both. In some cases, the transgressive relationship has not ended, and the therapist and supervisor are called upon to help bring it to an end. It must be recognized that there may be genuine attachment and even love between the parties (along with many other emotions or a great deal of ambivalence) so ending can involve major loss that must be expected and tended to. And losses may continue to accrue over time, creating additional sources of grief. It is also important to consider the impact upon and the needs of those who are damaged collaterally: spouses, partners, children, and other family members; colleagues; other patients; institutions; and the profession. Specialized interventions might need to be extended to them as well.
This article is but a snapshot of the complexities and intricacies that might attend sexual boundary violations in psychotherapy, as well as in other professional relationships. As discussed, these are not victimless situations and can cause enormous damage to the dyad and to collateral parties. However, in considering or being faced with them, the need for personal humility is evident. Any one of us could get caught in such a situation due to the vagaries and challenges of our life or life stage. Attention to our own mental health and a periodic check on our professional boundaries should occur routinely. In recognizing that “there but for the grace of God go I,” we can develop a greater capacity for intervention with colleagues and trainees, if we suspect that a therapy is becoming or has become compromised, and respond with concern and compassion rather than approbation and shame. The recent attention that the #MeToo movement has shed on this, and other forms of sexually inappropriate and coercive behavior has resulted in greater information about their occurrence that, in turn, hopefully leads to more informed intervention for all affected parties and continued efforts at prevention.
About the Author
Christine A. Courtois, PhD, ABPP, is a licensed and board certified counseling psychologist who has received recognition for her work on the effects of incest, child sexual abuse, complex traumatic stress disorders and other types of trauma and has received awards from numerous professional organizations. She is a psychotherapist (with broad experience in outpatient and inpatient treatment), workshop leader, and consultant specializing in posttraumatic and dissociative conditions and disorders.
References
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