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, especially1 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.
1 footnote
New Section
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).
- 1. texts
- 2. text sdlfk'as;j f'adsk mlfd
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.
Caption
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
Alpert, J. L., & Steinberg, A. (2017). Sexual boundary violations: A century of violations and a time to analyze. Psychoanalytic Psychology, 34(2), 144–150.
Celenza, A. (2011). Sexual boundary violations: Therapeutic, supervisory, and academic contexts. Jason Aronson.
Drum, K. B., & Littleton, H. L. (2014). Therapeutic boundaries in telepsychology: Unique issues and best practice recommendations. Professional Psychology: Research and Practice, 45(5), 309–315.
Freyd, J. J. (2018, January 11). When sexual assault victims speak out, their institutions often betray them. The Conversation. https://theconversation.com/whensexual-assault-victims-speak-out-their-institutions-often-betray-them-87050
Gabbard, G. O. (2017). Sexual boundary violations in psychoanalysis: A 30-year retrospective. In J. L. Alpert & A. Steinberg (Eds.). (2017). Psychoanalytic Psychology,4(2), 1–24.
Pope, K. S. (1993). Sexual feelings in psychotherapy. American Psychological Association.
Pope, K. S. (1990). Therapist-patient sexual involvement: A review of the research. Clinical Psychology Review, 10, 477-490.
Reamer, F. G. (2021). Ethics and risk management in online and distance behavioral health.
Cognella Academic Publishing.
Steinberg, A., & Alpert, J. (2017). Sexual boundary violations: An agenda deserving more
consideration. Psychoanalytic Psychology, 34(2), 221–226.
Steinberg, A., Alpert, J., & Courtois, C. A. (2021). Sexual boundary violations in psychotherapy:
Facing indiscretions, transgressions, and misconduct. American Psychological Association.
TELL, Therapist Exploitation Link Line.