This chapter, Sex Between Therapists and Patients, was published by Academic The therapeutic relationship is a special one, characterized by exceptional The ethics codes of all major mental health professionals prohibit the offense. In addition, therapists need to observe codes of ethics that aim to prevent them forming a personal relationship with a patient during or soon. A client asks if he can pay you for psychotherapy services by doing your . The ethics code of the American Psychological Association (APA.
Some may even feel it as intrusiveness. Asking before acting is essential. The client who brought coffee and sweets to the 10 a. She began to focus less on her own issues and more on that therapist as someone with whom she could have a relationship with outside of the office.
The therapist finally picked up on what was going on and attempted, unsuccessfully, to pull the relationship back to the business of therapy. The client experienced the request to cease bringing coffee and sweets as both an insult and a rejection.
She never returned to therapy. Although this case did not result in an ethics complaint, the therapist felt guilty over failing to better perceive how meeting his own needs for what seemed like an innocent pleasure caused pain for a client he liked.
The economically strapped landscaper provides a more complicated case, and we will have more to say about bartering later. However, in such cases, taking someone up on what seems like a good match can turn into an ordeal. Ultimately, the client successfully sued the therapist for exploitation. Unfortunately, the therapist became defensive and told the client that the client must have caused the damage.
The therapeutic alliance evaporated, and the client successfully sued the therapist in small claims court. Finally, certifying the need for an emotional support animal, as opposed to a trained service animal e. Crossing them has many potential effects. The work of mental health professionals is conducive to permeable role boundaries because so much of it occurs in the context of establishing emotionally meaningful relationships, very often regarding intimate matters that the client has not spoken of to anyone else.
Yet, mental health professionals continue to hold differing perceptions of role mingling. These perceptions range from conscious efforts to sustain objectivity by actively avoiding any interaction or discourse outside of therapeutic issues to loose policies whereby the distinction between therapist and best buddy almost evaporates.
However, even those who would stretch roles into other domains would condemn conspicuous exploitation of clients. Some mental health professionals decry the concept of professional boundaries, asserting that they promote psychotherapy as a mechanical technique rather than relating to clients as unique human beings.
Instead, acting as a fully human therapist provides the most constructive way to enhance personal connectedness and honesty in therapeutic relationships Hedges, and may actually improve professional judgment Tomm, Those critical of setting firm professional boundaries further assert that role overlaps become inevitable and that attempting to control them by invoking authority e. The answer, they say, involves educating both clients and therapists about unavoidable breaks and disruptions in boundaries and to ensure that therapists understand that exploitation is always unethical, regardless of boundary issues.
As the scenarios at the onset of this course reveal, however, exploitation is not the only harmful result of boundary crossings. We believe that the therapist retains ultimate responsibility for keeping the process focused. We see no reason why maintaining professional boundaries needs to diminish a therapist's warmth, empathy, and compassion. The correct task is to match therapy style and technique to a given client's needs Bennett et al.
Furthermore, we believe that lax professional boundaries can act as a precursor to exploitation, confusion, and loss of professional objectivity. Conflicts, which are more likely to arise when boundaries blur, compromise the disinterest as opposed to lack of interest prerequisite for sound professional judgment.
As Borys contended, clear and consistent boundaries provide a structured arena, and this may constitute a curative factor in itself. In short, the therapy relationship should remain a safe sanctuary Barnett, that allows clients to focus on themselves and their needs while receiving clear, clean feedback and guidance. Frank discussions about boundaries with clients during the initial informed consent phase is also recommended.
Cultural traditions, geography e. The ethics code of the American Psychological Association APA, offers a clear definition of multiple role relationships. Multiple role relationships occur when a therapist already has a professional role with a person and: Is also in another role with the same person, or Is also in a relationship with someone closely associated with or related to the person with whom the therapist has the professional relationship, or Makes promises to enter into another relationship in the future with the person or a person closely associated with or related to the person.
To qualify for the definition of multiple role relationship then, the initial relationship typically requires an established connectedness between the parties. The primary role relationship is usually with an ongoing therapy, counseling client, student, or supervisee. Limited or inconsequential contacts that grow out of chance encounters would not normally fall under the definition or cause for any ethical concerns. Multiple role relationships may occur via action, as when a therapist hires a client as a housekeeper.
Or they can take the form of a proposal for the future while therapy remains ongoing, as when a therapist and a client plan to go into business together or agree to start a sexual relationship upon termination of therapy, thus altering the dynamics of the ongoing professional relationship.
Zur has categorized multiple role relationships by types.
These categories are illustrated in the cases offered here. Nonsexual consecutive role relationships with ex-clients do not fall under any specific prohibitions in the APA code APA, However, based on post-therapy incidents described in this course, we advise caution even after a natural termination of the professional relationship. However, not all multiple role relationships with clients are necessarily unethical so long as no exploitation or risk of harm to the client or the professional relationship can be reasonably expected.
We agree that careful consideration should occur prior to softening the boundaries of any professional role, and we also remain unconvinced that accurate outcome predictions involve a simple exercise in judgment.
If that were so, therapists would have the lowest divorce rate of any professional group! Alas, no evidence of such foresight exists. We also contend that justification for entering into some types of multiple role relationships with persons in active treatment does not exist.
Sexual and business relationships, for example, pose inherent risks regardless of who is involved. Neither can be defended as reasonable dimensions to impose on a therapy relationship. Finally, we will comment on how easy it is to rationalize, to convince ourselves that an action is justifiable in a particular situation.
All therapists are vulnerable to self-delusion when their own needs get in the way, even those who are competent and have been scrupulously ethical in the past e. Risk Assessment Kitchener suggests assessing the appropriateness of boundaries by using three guidelines to predict the amount of damage that role blending might create. Role conflict occurs, says Kitchener, when expectations in one role involve actions or behavior incompatible with another role.
First, as the expectations of professionals and those they serve become more incompatible, the potential for harm increases. Second, as obligations associated with the roles become increasingly divergent, the risks of loss of objectivity and divided loyalties rise.
Third, to the extent that the power and prestige of the psychotherapist exceeds that of the client, the potential for exploitation is heightened. Thus, if after two years of intense therapy and a tenuous termination whereby the client may need to return at any time, no additional roles should be contemplated.
The success or failure of this new role relationship would be more about what the parties do as consenting adults as opposed to the brief professional experience.
Brown adds two additional factors that, if present, heighten the risks of harm. Second, boundary violations usually arise from impulse rather than from carefully reasoned consideration of any therapeutic indications.
Thus, hugging a client is not unethical per se, but an assessment of any potential hazards or misunderstandings should precede such an act.
Risky Therapists All therapists face some risk for inappropriate role blending Keith-Spiegel, Those with underdeveloped competencies or poor training may prove more prone to improperly blending roles with clients. However, even those with excellent training and high levels of competence may relate unacceptably with those with whom they work because their own boundaries fail. Some may feel a need for adoration, power, or social connection. The settings are private and intimate.
The authority falls on the side of the therapist. Moreover, if things turn sour, the therapist can simply eliminate the relationship by unilaterally terminating the client and can deny that anything untoward occurred should a complaint be initiated by a client.
Indeed, when a client walks through the door, immediate clues become apparent: Multiple authors have discussed the advantages of self-disclosure. Done thoughtfully and judiciously, revealing pertinent information about oneself can facilitate empathy, build trust, and strengthen the therapeutic alliance e.
However, those who engage in considerable and revealing self-disclosure with clients stand at greater risk for forming problematic relationships with them. Instead, this client began to feel that the therapy environment was polluted rather than safe and clean. She quit therapy feeling even more adrift. It is difficult to know in advance how a given client will respond to a self-disclosure, particularly when the subject is in sensitive territory for the client.
It seems reasonable to expect that some clients would want to know as much as possible about the person in whom they are placing so much trust.
A skillful therapist can respond without demeaning the client in the process. At the same time Internet searches make considerable information on anyone readily available.Ethics- Client & Therapist Relationships
Like any other individual who prefers some modicum of privacy, psychotherapists must understand that information posted on personal and social sites will become known to curious clients and may lead to inquiries or promote some other types of boundary blurring. See Kolmes, ; Reamer, The next case involves an indignant response to a fading career, compounded by an absence of close ties with family or friends. Grandiose might elicit some sympathy were it not for her ill-conceived approach to dealing with her own issues.
A well-known and outspoken therapist, Panacea Grandiose, Ph. However, Grandiose continued to maintain a successful practice, and her clients became the focus of her life. She hosted frequent social events in her home and invited herself along on clients' vacations.
It seems that something about therapists either choosing to work in isolation, or the isolating conditions themselves, foster the potential clouding of professional standards of care. Or perhaps some therapists have experienced rejection by their colleagues, as with Dr.
Sex Between Therapists and Clients
Grandiose, and turn to inappropriate substitutes for support and validation. Regardless of the reason, an insular practice with no provisions for ongoing professional contact diffuses professional identity, thus putting appropriate decision-making at risk. Therapeutic Orientation and Specialty Practices Some therapists practicing within certain therapeutic orientations are probably more vulnerable to charges of boundary violations.
For example, Williams notes that humanistic therapy and encounter group philosophies depend heavily on tearing down interpersonal boundaries.
Such therapists often disclose a great deal about themselves, hug their clients, and insist on the use of first names.
These therapists also become, according to Williams, vulnerable to ethics charges even though their practice is consistent with their training. Some therapists who specialize in working with a particular population or in certain settings may need to exercise extra vigilance because the nature of the services or service settings are conducive to or even require relaxed boundaries. In such instances, very fuzzy edges may constitute an inherent element of practice rather than qualifying as inappropriate.
Devine experienced deep sadness, hopelessness, and questioned her faith. At that time, Pew was dealing with his own troubles and struggling to manage his large congregation. Devine relayed her feelings, blaming God for having forsaken her, Rev. Pew responded by pouring out details of his own family problems, including the particulars of a drinking problem in his youth.
Pew hoped this intense session would prove helpful, figuring that Devine would gain confidence from knowing that even he had to face and overcome hardships. Devine, however, became upset by these revelations, passed them along to other parishioners, and left the church. He also interjected too much of his own life while failing to recognize that Ms.
Devine asked Pew for spiritual guidance only. Pew should have focused on his role as a pastor and simultaneously referred Ms. Devine to someone competent to treat her depression. However, therapists who belong to a religious community as parishioners can also easily experience challenging multiple roles.
Funnel Mask sought the professional assistance of Shudi Tell, M. They may have been led to believe that the sexual relationship was an act of great self-sacrifice on the part of the therapist, a moral and ethical act that was the only way that the therapist could "cure" whatever was wrong with the patient. Ambivalence of this kind is often found among those who have experienced other forms of abuse.
Incest survivors, for example, may experience contradictory impulses to flee the abusive parent, and yet also to cling to and protect that same parent. Similarly, some battered women will desperately want to escape to safety but also feel an overwhelming impulse to submit to the batterer, to take all blame upon themselves, and to keep the battering secret from all others.
Cognitive Dysfunction Many people who have been sexually involved with a therapist, whether the sex started before or after termination, will experience intense forms of cognitive dysfunction. There may be interference with attention, memory, and concentration. The flow of experience will often been interrupted by unbidden thoughts, intrusive images, flashbacks, memory fragments, or nightmares.
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These cognitive impairments may interfere significantly with the person's ability to work, to participate in social activities, and sometimes even to carry out the most routine aspects of self-care. Sometimes the pattern of consequences may fit the model of post-traumatic stress disorder.
Emotional Lability Emotional lability reflects the severe disruption of the person's characteristic ways of feeling in a way that is similar to cognitive dysfunction reflecting the severe disruption of the person's characteristic ways of thinking. Intense emotions may erupt suddenly and without seeming cause, as if they were completely unrelated to the current situation. The emotional disconnect can be profound: Emotions begin to feel alien and threatening, as if they were unwanted intruders into the inner life.
Cognitive dysfunction can involve interrupting the flow of experience with unbidden thoughts, intrusive images, etc. The person begins to feel helpless, as if the emotions were completely out of control, as if he or she were at the mercy of a powerful, intrusive enemy, an occupying force. Emptiness and Isolation People who have been sexually involved with a therapist may experience a subsequent sense of emptiness, as if their sense of self had been hollowed out, permanently taken away from them.
The sense of emptiness is often accompanied by a sense of isolation, as if they were no longer members of society, cut off forever from feeling a social bond with other people. She wrote in If I am alone, I will cease to exist. Guilt People who become sexually involved with a therapist may become flooded with persistent, irrational guilt.
The guilt is irrational because it is in all instances the therapist's responsibility to avoid sexually abusing a patient. It is the therapist who has been taught, from the earliest days of training, that engaging in sex with patients is prohibited, no matter what the rationale.
It is the therapist whose ethics code clearly classifies sexual involvement with patients as a violation of ethical behavior. It is the therapist who is licensed by the state in recognition of the need to protect patients from unethical, unscrupulous, and harmful practices, and it is the licensing boards and regulations that clearly charge therapists with refraining from this form of behavior that can place patients at risk for pervasive harm. As the research summarized in subsequent sections will show, gender effects in this area are significant.
It is possible that gender may be associated with the ways in which this irrational guilt develops and is sustained. Psychiatrists Melanie Carr and Gail Robinson wrote: The almost universal expression of guilt and shame expressed by women who have been sexually involved with their therapists is a testament to the power of this conditioning" p.
Psychiatrist Virginia Davidson, analyzing the similarities between therapist-patient sex and rape, wrote: Women victims in both instances experience considerable guilt, risk loss of love and self-esteem, and often feel that they may have done something to "cause" the seduction. As with rape victims, women patients can expect to be blamed for the event and will have difficulty finding a sympathetic audience for their complaint.
Added to these difficulties is the reality that each woman has consulted a therapist, thereby giving some evidence of psychological disequilibrium prior to the seduction. How the therapist may use this information after the woman decides to discuss the situation with someone else can surely dissuade many women from revealing these experiences.
Impaired Ability to Trust When therapists intentionally and knowingly violate their patients' trust, as they do when they decide to become sexually involved with them, the effects on the patients' ability to trust can be profound and lasting.
Therapy may rest on a foundation of exceptional trust. People may walk into the offices of complete strangers and, if the stranger is a therapist, begin talking about thoughts, feelings, and impulses that they would reveal literally to no one else. Every state, appreciating the exceptionally sensitive nature of the "secrets" that patients may entrust to their therapists, have established in their laws a formal therapist-patient privilege. The ethics codes of all major mental health professions recognize the therapist's responsibility to maintain confidentiality when patients trust the therapist to the extent that they disclose personal information in therapy.
Beyond investing therapists with trust regarding their own privacy, confidentiality, and "secrets," patients trust therapists to act in a way consistent with patient well-fare and to avoid intentionally engaging in any behavior that not only is unethical and prohibited by law but also places the patient at so needless a risk for harm. In some ways, therapy is similar to surgery. Patients agreeing to surgery allow themselves to be opened up physically because they have been led to believe that the process has some reasonable prospects of leading to improvement.
They allow a professional to do to them--i. They trust that the professional will not take advantage of them or abuse them, sexually or otherwise, during this process.
Therapy patients submit themselves to a process in which they open up psychologically because they also have been led to believe that this process is likely to yield improvement.
They trust therapists to avoid any exploitation or abuse during the process. It was Freud who first noted this similarity. He wrote that "talking therapy" was "comparable to a surgical operation. Increased Suicidal Risk As a group, patients who have been sexually involved with a therapist have significantly increased risk of both suicide attempts and completed suicides when compared with the general population and other groups of patients.
Role Reversal and Boundary Confusion Therapists who sexually exploit their patients tend to violate both roles and boundaries in therapy. The focus of sessions shifts from the clinical needs of the patient to the personal desires of the therapist. The therapist brings about a reversal of roles: The fundamental clinical, ethical, and legal boundary that would prevent a therapist from turning patients into sources for the therapist of sexual pleasure, experimentation, relief, variety, or control is violated.
In a legitimate therapy, the therapeutic process, effectiveness, and improvements that therapist and patient work on during each sessions is expected to continue between sessions and, ultimately, after termination.
Entering psychotherapy to become less depressed, to overcome stage fright, or to resolve conflicts with a partner would make little long-term sense if the depression stage fright, and conflict resumed immediately after termination.
Unfortunately, the harm as well as the benefits that therapy brings about can be long-term. The negative effects of the therapist's violation of boundaries and reversal of roles can generalize beyond the therapy and persist long after the termination of the therapy and the sexual relationship.
The roles and boundaries that people use to define, mediate, and protect the self may become not only useless for the patient but also self-defeating and self-destructive. Sexual Confusion It is perhaps not surprising that many patients who have been sexually exploited by a therapist wind up deeply confused about their own sexuality.
Psychologist Janet Sonne served as one of the group therapists in and for some of the patients who participated in the UCLA Post Therapy Support Program, the first university-based program offering services to patients who had been sexually involved with their therapists, conducting research in this area, and providing training to graduate students.
She wrote that female patients who had been sexually involved with a prior therapist "expressed a cautiousness or even disgust with their sexual impulses and behavior as a result of sexual involvement with their previous therapists. For some female clients who identified themselves as heterosexual before they were involved sexually with female therapists, there tended to be significant confusion over their 'true' sexual orientation.
Some engage in sex with others on an almost obsessional basis as re-enactment of the sexual relationship with the therapist. Especially when the patient is experiencing feelings of emptiness and isolation, the specific sexual activities previously experienced with the exploitive therapist--often re-enacted in the midst of flashbacks--may represent an attempt to fill up the self and break through the isolation.
For still other patients, sex becomes associated with feelings of irrational guilt. They may engage in demeaning, degrading, joyless, painful, harmful, or dangerous sexual activities that seem to express the conviction: Suppressed Anger Many patients who have been sexually abused by a therapist are justifiably angry, but it may be difficult for them to experience the anger directly.
Some may feel only numbness in situations that, according to them, would have previously evoked anger.