This is a beginning to intermediate level course. Upon completion of this course, mental health professionals will be able to:
Authors’ Note: Almost all case scenarios presented in this course are adapted from actual incidents. We use improbable names throughout to enhance interest and ensure that identities of all parties are not discernible. It is not our intention to trivialize the seriousness of the issues. As part of our disguising process, we also randomly assign various professional designations, earned degrees or licensure status. Also, for ease of presentation, we use the term "therapist" throughout to refer to anyone delivering psychotherapy or counseling services to clients.
The materials in this course are based on current published ethical standards and the most accurate information available to the authors at the time of writing. Many ethical challenges arise on the basis of highly variable and unpredictable contextual factors. This course material will equip clinicians to have a basic understanding of core ethical principles and standards related to the topics discussed and to ethical decision making generally, but cannot cover every possible circumstance. When in doubt, we advise consultation with knowledgeable colleagues and/or professional association ethics committees.
Let the fear of danger be a spur to prevent it; he that fears not, gives advantage to the danger.
Francis Quarles (1592-1644)
The quote from poet Francis Quarles mirrors our belief that awareness is essential to avoiding ethical pitfalls involving psychotherapy and counseling clients. Mental health professionals may puzzle over how intelligent, educated men and women could so foolishly engage in unprofessional and unethical behaviors that pose significant threat to themselves and their clients.
One might assume that therapists found guilty of forming high risk relationships with clients consist chiefly of poorly trained, obtuse, or psychopathic individuals. Amazingly, actual cases of serious infractions from our personal experience serving on ethics committees include more than one past president of state psychological associations, current and former members of state licensing boards, a professor at a major university who authored an article on professional ethics, and even chair of a state psychological association ethics committee!
Although one can identify various types of high risk therapists and situations, we have also concluded that no one seems immune from temptation. Psychotherapeutic alliances have peculiar and significant features that require particularly firm professional resolve and self-monitoring. Twemlow and Gabbard (1989) put it bluntly; “Every psychotherapist struggles with the temptation to seek personal gratification from the therapeutic situation” (p. 71).
Circumstances can converge to form a “perfect storm” of vulnerability or temptation. Consider the following scenarios adapted from our case files:
The first scenario represents the most frequently reported type of temptation. Therapists become unhappy with their personal lives. Along comes an attractive client who appears to hold out the prospect for removing (or at least masking) the therapist’s personal misery. In the actual case, a brief affair soon ensued and proved unsatisfactory to both parties. The therapist did not prove to be the amazing lover the client had fantasized, and, as the therapist told the ethics committee after the client pressed charges, “I learned the hard way why this client needed psychotherapy.” The professional association expelled the therapist and notified the licensing board in his state.
The second scenario illustrates one of those situations that can so easily be perceived as a “great deal” What could go wrong? The two already experienced how well they worked together. However, the actual case resulted in calamity. The therapist invested more than he could afford in the client’s business and found the client a castigating and controlling boss. When the therapist said he wanted out and a return of his investment the client refused, noting that they had signed a valid contract. The client also pressed ethics charges against the therapist for “forcing his way into my business.”
The third scenario seems more innocent, but the outcome in the actual case resulted in a sustained ethics charge of client exploitation. The therapist did purchase a number of items at the greatly reduced price from the client’s boutique. Nevertheless, the therapy proceeded poorly. The client became increasingly defensive and resistant to the therapist’s advice, eventually stalking out and leaving an unpaid bill for the last two sessions. When the therapist attempted to collect her fees using a collection agency, the client pressed an ethics complaint charging that the therapist was only after her money and her merchandise.
The fourth scenario has a couple of unusual features in that the counselor did not know much about the client; The group focused solely on test-taking anxiety as opposed to the more sensitive issues that come up in individual psychotherapy. Yet, agreeing to meet in a very cozy setting with someone who had come for help, even in a carefully circumscribed way, always holds the potential of putting the therapist in jeopardy. “Know your client before crossing any professional boundaries” is a theme that will recur several times in this lesson. In the actual case, the client felt embarrassed by a brash rejection and later attempted to press ethics charges for “getting him drunk and trying to take advantage.” The charge was not sustained, but the therapist had to endure a difficult inquiry by his peers, and his once-prized student turned against the therapist and was, himself, needlessly hurt.
The final scenario may seem a bit out of place. After all, the therapist tried to do the client a favor. Allowing clients the opportunity to run up large bills, however, runs the risk that they may never acquire the resources to pay them off. The therapist who served as a safe haven for this fragile client has now superimposed the role of lender. In the actual case, the client ran up a huge tab, never found work, felt intense guilt over the inability to pay back the large sum to the person on whom he had depended, and attempted suicide.
This lesson will focus on high risk behaviors that can sneak up on therapists who do not pay sufficient attention to their professional responsibilities. Reasons include giving in to their own vulnerabilities, rationalizing their actions as acceptable, crossing over a line after a number of seemingly innocent baby steps, or simply being caught off guard and failing to make an appropriate decision. Most of these behaviors involve sexual, financial, or authority issues – the very same interpersonal issues that get us into trouble outside of our professional offices.
As we saw in one of the opening scenarios, business partnerships are vulnerable to interpersonal conflict and financial risk. In the context of that certainty, it seems surprising that mental health professionals have willfully undertaken risky business associations with their clients. There is no such thing as “strictly business” when one of the partners has a fiduciary duty to uphold the trust and ensure the personal welfare of the other. Other similar ventures that have gone awry illustrate the damage done to both therapists and their clients:
No rational person goes into business unless a prospect to profit financially seems likely, which puts immediate and complicating expectations and pressures on dual role clients. Greed played a large role in both Grabbit's and Dip’s cases, even though neither would likely admit it. They became entangled in business dealings to the detriment of their clients’ needs and ultimately to their own welfare. Each one should have reasonably foreseen that these deals could impair their objectivity and judgment. Grabbit ultimately did lose her entire investment and received a formal admonition from the licensing board. Ms. Dip believed that because Sculpt instigated the partnership and because she terminated the therapy with him, she had no responsibility for what ultimately transpired. On the contrary, the responsibility rested exclusively with her because she should have foreseen the potential hitch in such a plan. Terminating a client for the purpose of going into business constitutes unacceptable professional practice, even if Dip did assist Sculpt in finding a new therapist. If Dip files a lawsuit, she will find the tables turning on her.
The workplace breeds multiple role relationships. Many prove positive and enhance the quality of our lives. Employees and their supervisors are often friendly, care about each other's welfare, and attend some of the same social events. The workplace can also be rife with land mines – gossip, conflicts, incivility, competition for promotions and resources, and difficult co-workers – all of which contribute to the potential for volatility. Therefore, mental health professionals must remain vigilant to this ever-changing environment and avoid complicating it by willfully appending their services to those they work with. Employees almost always have reasonable external alternatives for needed psychotherapy or counseling.
Jan Typer worked as a records clerk for a community mental health agency. Helmut Honcho, Ph.D. supervised her work. When Ms. Typer experienced some personal problems, she asked Dr. Honcho if he would counsel her. He agreed. Ms. Typer later issued an ethics complaint against Honcho, charging him with blocking her promotion based on assessments of her as a client instead of on her performance as an employee.
It may prove impossible to unravel the true basis for any job-related decision in such situations. Whether valid or not, Ms. Typer can always interpret any unpleasant reactions to what happens on the job as linked to the therapy, or vice-versa. When a client is also an employee, the consequences of a multiple role relationship gone awry can be especially devastating because of the potentially adverse career and economic ramifications for the client and sometimes the employer if a complaint is sustained. Dr. Honcho should have known better.
Renega Lease, L.I.C.S.W., owned an apartment building where William Wrench lived and served as the on-site manager. Wrench and his wife asked Ms. Lease to see them for couples counseling. During the second session, Lease learned from the wife that Wrench was a habitual drinker. Lease summarily terminated Mr. Wrench as a client and fired him as her building manager, thus forcing him and his wife to relocate.
Information shared in one sector of a relationship influences the entire relationship. Whereas Lease has a right to expect sober management of her apartment complex, she unethically used information shared in confidence to the detriment of her client.
Therapy clients who possess special skills will inevitably lead to some degree of temptation to consider what skills these clients might have to offer you. Moreover, many clients feel financially strapped in this difficult economy. Offering to employ them may seem like a good deed. However, as with business relationships, such alliances are fraught with risk that can obliterate the professional relationship and disperse additional emotional and financial debris in its wake.
Oscar Scatterbill, Ph.D. hired client Thomas Clerk as his personal secretary and bookkeeper. The relationship seemed to be working well until Clerk asked for a raise. Dr. Scatterbill refused, saying that Clerk already earned a good hourly wage. Clerk countered by reciting Scatterbill's monthly income and comparing it to his own. Dr. Scatterbill allegedly laughed, responding that a comparison between the two was ludicrous. An insulted Clerk quit his job as well as his therapy, and wrote to an ethics committee claiming that Dr. Scatterbill had “ruined his life.”
Dr. Scatterbill should have known better than to employ an ongoing client, especially for such a sensitive position that gave the client access to confidential information. Different roles call for different protocols, and the roles of “therapist” and “boss'” require conflicting interaction styles.
Click Shutter needed additional work to make overdue payments on a new car. When Click offered to photograph the upcoming wedding of his counselor at half price, Melvin Groom, L.M.F.T. agreed. However, the bride found the photographs unacceptable (asserting that they made her “look fat”) and insisted that Groom not pay Shutter. In the meantime, Shutter increased the agreed-upon price because the bride’s demands to photograph her from multiple angles caused him extra work and expense. Shutter quit therapy, told everyone in town that Groom had married a witch, and successfully sued Groom in small claims court.
That Shutter was saddled with payment on a car he could not afford was not Groom’s problem to solve. Groom might have politely refused Shutter’s offer, noting that the couple had finalized their wedding plans. Even in situations where the task seems specific and time-limited, clear judgment must supersede giving in to what appears on the surface to be a reasonable arrangement. In the meantime, Groom’s reputation in the community suffered.
Mental health professionals often receive words of sincere appreciation from clients. Sometimes an expression of gratitude extends beyond a verbal or written thank-you. Holiday periods and the termination session are the most likely times that some clients will bestow gifts (Amos & Margison, 2006). Accepting a small material token, such as homemade cookies or an appropriate inexpensive item, typically poses no ethical problem. At times, however, accepting certain types of gifts (e.g. a nude calendar, boxer shorts, a condom, or any other highly personal or emotionally-laden item) would more appropriately require discussion about the client’s meaning and motives, regardless of the cost.
As we all know, gift giving may reflect motives that have nothing to do with appreciation. Gifts have the power to control, manipulate, or symbolize far more than the recipient can fully understand. Some clients may even attempt to equalize power within the relationship by bestowing a gift (Knox, Hess, Williams, et al., 2003). When a gift goes beyond a simple gesture of gratitude, problems of ethics and competent professional judgment arise (Barnett, 2011). The following cases demonstrate ethical boundary crossing with adverse consequences, especially in the case of expensive gifts.
Wealthy Rich Porsche gave his recently licensed therapist, Grad Freshly, Ph.D. a new car for Christmas, accompanied by a card stating, “To the only man who ever helped me.” Dr. Freshly felt flattered and excited. He convinced himself that his services were worth the bonus because Porsche recounted how he had churned through many previous therapists with disappointing results. As a more seasoned therapist would have predicted, Rich soon began to find fault with Dr. Freshly and sued him for manipulating him into giving an expensive gift.
This case illustrates naiveté and inexperience, a fairly common denominator among therapists who accept gifts beyond the realm of small one-time or appropriate special occasion tokens. Regardless of any other dynamics or considerations, a very valuable gift should be refused. A person in a vulnerable situation can always charge exploitation later, and such a charge may well have substance despite the recipient’s rationalizations. Freshly’s case qualifies as unusual, but also illustrates how blindly satisfying one’s own interests can lead to trouble later. (Barnett, 2011).
Sharp Dresser, L.I.C.S.W., was surprised when her clothing designer client walked in carrying a magnificent business suit. “I made this just for you,” the client declared. Dresser made the mistake of accepting it without further thought, particularly since the client was in the middle of a messy child custody dispute and Dresser didn’t want to upset her by refusing it. However, Dresser already knew that the client had an agenda, namely to convince him to testify that the client’s father had abused the children. When Dresser steadfastly refused because he had no credible evidence of any abuse, the client became furious and contacted an ethics committee charging that Dresser manipulated her into creating an expensive outfit.
Aside from the expense of the suit, Mr, Dresser succumbed to his personal needs and failed to heed the huge warning sign. If the client wanted someone to lie in court for her, about what else might she fib? Although the ethics committee did not find Dresser guilty of exploiting his client, it did admonish him for poor professional judgment.
A grateful elderly client gave Salvador Time, Ph.D. her father’s solid gold and engraved watch. When the client’s son learned of the gift, he pressed ethics charges. The son had wanted the watch all along, but never pressured his mother, figuring he would inherit it after she passed. In his defense, Dr. Time argued that the client, as an adult, had the right to decide to give her possessions to whomever she wanted. Dr. Time also contended that the client would have felt highly offended had he declined her gift.
The ethics committee did not find Dr. Time’s reasoning acceptable. It concluded that Time knew that the client had adult male children and male grandchildren. He should have recognized this personal and valuable item as a family heirloom.
Therapists who work in isolation, compared to those in group psychotherapy or counseling practices or clinic/hospital settings, may be more prone to look to clients to fulfill their own needs, compared with those in institutional practice. Although we know of no large scale study, your authors – who have served on several ethics committees, including that of the American Psychological Association – noticed that a disproportionate number of ethics charges were lodged against therapists practicing in relative isolation (e.g. working in a secluded office, an office building with no other practitioners close by, or a private home office). Most of these cases involved inappropriate and high risk boundary violations.
Ivan Lonely, M.A. saw clients in a small office on an upper floor of a bank building. He admitted feeling cut off from collegial support when questioned by a licensing board regarding a teenage client whose condition deteriorated significantly under his care. The parents had charged Lonely with incompetence.
Perhaps had Mr. Lonely worked in an office with other mental health professionals nearby, or was a member of a peer discussion group, he might have received sound ideas as to how to proceed with this client. They may have persuaded him to refer the client to a more suitable colleague, thus avoiding harm to his client as well as to himself.
The increasing popularity of working out of one’s home is understandable from both convenience and financial standpoints. While not inherently inappropriate, we do not advise conducting psychotherapy or counseling in one’s home.
Chester Homebody, DSW did not anticipate the problems he would cause for his family by taking on Cling Blue, a depressed and needy client diagnosed as having a borderline personality disorder, in his remodeled garage home office. After the first few sessions, Blue started showing up at the house almost every day, asking if he could help with the yard or walk the dog or play with Homebody’s children. Homebody’s wife felt extremely uncomfortable about Blue’s approaches to their children. Homebody’s attempts to gently dissuade Blue’s behavior resulted in only short-term compliance. Homebody finally terminated Blue and told him he would have to get a restraining order if he ever came around again. Blue contacted a lawyer, which prolonged the ordeal for both client and therapist.
If one must conduct therapy in a private home, the consulting room should have furnishings that mark it as therapy professional office, with its own entrance. Some clients, however, may find receiving therapy anywhere in the therapist's home (even a dedicated home office) confusing, and their emotional status could become compromised by connotations attached to their therapist’s living conditions.
Carl Comfort conducted therapy in a guest bedroom. Clients had to come in through the living room and walk down the hall past other bedrooms to get to the “office.” The office room contained a daybed, a small desk and desk chair, and two armchairs. The color scheme was pink and purple. Connie Fused developed a strong attachment to Comfort. During one session, she asked if Comfort would allow her to continue the session lying on the bed. She felt rejected when Comfort laughed. She never returned. Comfort was startled to receive notice that Fused had filed a complaint against him for sexual harassment.
Some clients seen in private homes could act out in frightening ways. Unless the home-office therapist has another location available to screen new clients for suitability, one cannot completely know in advance who will walk through the door.
In short, a professional office setting and maintaining a solid professional identity by having easy access to colleagues can preclude serious incidents.
Transparency is increasingly unavoidable for all people, leaving psychotherapists facing “small world ethics” challenges (Lannin & Scott, 2013). Those who fail to responsibly use new technologies and who blur professional and social boundaries can face embarrassment and other unwanted consequences (Devi, 2011; Gabbard, Roberts, Crisp-Han, et al., 2011), Keeping in mind that any e-mail message can be shared with anyone else may help avoid mishaps. Some of these mishaps are of the therapists’ own making, even if they failed to perceive the consequences in advance.
Nathan Myopia, PhD, put the following on his Facebook page: “Having a bad day. My clients drive me nuts. Today was the worst because two of them I don’t really like.”
It did not take long for a client to hear of this post, and she made sure her friends in this small town knew how Dr. Myopia described his clients online. Another client who was eventually in on the message chain filed an ethics complaint.
Whether a psychotherapist or counselor should maintain a Facebook or other publically accessible social media page can be debated. Nothing is truly confidential, even when one restricts access to certain individuals. Dr. Myopia insulted his clients directly; however even if Facebook commentary and photos are about oneself and seemingly “safe” topics and images, such disclosures can be problematic.
Manny Stalk accessed his therapist’s (unrestricted) Facebook page and reviewed multiple photographs of the therapist’s new home. Manny eventually located the address through the photos and frightened the family by sitting in his car outside most evenings. The therapy alliance was destroyed and the client faced legal consequences.
In the types of examples so far the therapists could have been more protective of themselves by thinking before posting and minimizing access to their personal lives and opinions. Sometimes that is not possible, which creates an especially difficult challenge. Therapists can be blindsided by a negative review that anyone can see, and such a review can result in the loss of potential business.
Review sites allow clients to share experiences with their health providers, including counselors and psychotherapists, with the public. Those who are justifiably aggrieved as well as the disgruntled can express themselves – often anonymously – with only a few restrictions on the content.
An individual, going by the pseudonym “ghostwriter,” wrote the following on an online review site: “If you need psychotherapy, stay away from Fenster Snide, PhD. He does not listen to what you are trying to tell him, laughs at your problems, and is unprofessional in his billing practices. He charges way too much, and you get nothing for your money.”A client wrote a scathing comment about the “poor-quality” therapy he received from Upsetta Peeved, LCSW and posted it on Yelp. Ms. Peeved entered a scathing response about her ex-client’s anger issues, suggesting that the client was also possibly dangerous. The client wrote to an ethics committee claiming that Ms. Peeved violated his rights to confidentiality and made defamatory statements about his character.
Can such reviews be removed? It is far more difficult than one might think. The First Amendment of our Constitution gives citizens considerable leeway in what they can say in public. Review sites such as Yelp contend that they are not in a position to judge the veracity of reviews posted on their sites and have statutory immunity. A review may be removed if they receive a court order to do so. That puts the therapist in an impossible situation – how can this statement be proven false and defaming? Kolmes and Ballard offer suggestions for “burying” bad reviews (see http://www.psyfin.com/articles/0411_yelp_attack.htm), that involve some labor intensive methods, such as bolstering your own profile on Yelp and creating more posts on Google to supersede the negative comment if one searches your name, creating a client satisfaction survey and posting that data, and attracting more positive reviews from those with whom you have a non-confidential relationship. (Asking clients to post positive reviews seems like the best fix but, of course, creates new ethical problems and is therefore not advised) The sad fact remains that people are drawn to critical reviews, and when other suitable psychotherapists are available to those checking out their options, those with all positive reviews may get the call.So, can you respond to a bad reviewer? Whereas electronic media has left everyone vulnerable to unfortunate and possibly biased or untrue public criticism, it should be noted that Ms. Peeved does not have the same luxury with regards to her client, or even an ex-client. What was shared during therapy does not become irrelevant after the relationship has terminated, Thus, responding directly is ethically risky. The obvious question is how to avoid bad reviews in the first place. After all, not everyone will be satisfied with their therapy, despite the competence and ethical sensitivity of their therapists. The best we can offer is to be extra sensitive to dissatisfied clients, and attempt to work though their complaints, even if only to terminate on reasonably good terms.
We do not intend this course as a lesson of forensic mental health practice. Detailed ethical guidelines for forensic practitioners may be found elsewhere (APA, 2013). However, practitioners often get into difficulties when they unintendedly stumble or find themselves sucked into a role within the legal system. Consider the following examples.
Merilee Testing, Ph.D. undertook a learning disabilities assessment referral from a local school system. The 8 year old child proved uncooperative, but his divorced mother commented, “He’s usually better behaved for his father. Can we schedule another appointment? At the second appointment the father brought in the boy and the child cooperated fully with the assessment procedures. In her report Dr. Testing wrote a 12 page neuropsychological assessment report that included 18 recommendations for improving the child’s school performance. One of the recommendations dealt with the child’s frequent refusal to do homework. Dr. Testing suggested, “The child seems to attend to tasks better under his father’s influence, so perhaps the father should be involved in supervising more of the child’s homework. Without consulting Dr. Testing the father went to court arguing for more significant physical custody of his son based in part on her recommendation regarding homework. Dr. Testing vigorously asserted that she had not intended to make any recommendation about a change of custody, but a state licensing board censured her for making a recommendation relative to such a change after the mother complained.
Wanda Wounded brought her four year old daughter, Wendy, to see Sara Sustenance, L.I.C.S.W. after noticing signs of emotional distress in the child. Ms. Sustenance suspected that Wendy might have been sexually abused based on some of the child’s comments. She reported her concerns to child protective services and an investigation led to criminal charges against an employee of the day care program Wendy attended. Ms. Wounded kept Wendy in treatment with Ms. Sustenance who inquired about and pursued details of the events in question as a way to help Wendy “process the trauma and work it through,” even though Wendy had not raised it as a continuing issue. Later at trial, Wendy’s testimony seemed far more detailed and serious than what she disclosed during her interview with child protective services. The defense attorney for the day care employee accused Ms. Sustenance of witness tampering by discussing and re-discussing the case with Wendy.
Carlos Danger, M.D. had stated expertise as a “trauma therapy expert.” Local attorneys frequently send their clients who have suffered automobile accidents, dog bites, and emotional distress in the workplace to Dr. Danger for treatment a few months ahead of filing lawsuits for civil damages. He invariably views such patients as deeply troubled and in need of long term therapy for severe trauma. He often agrees to delay billing for his services until after the clients’ lawsuits are settled.
Each of these cases illustrates the potential incompatibility of therapeutic and investigative roles, particularly when legal issues may come into play. Whenever possible, the therapist needs to anticipate when a case may have legal implications and take care to avoid inadvertent or compromising role shifting. This may require asking the question, “Who is the client?” and, ”To whom do I owe professional responsibilities?”
Dr. Testing took on an assignment for a school system. It seemed a straight-forward learning disability assessment, but things went afoul when she failed to recognize that her recommendations might be used manipulatively by angry divorced parents, leaving her dragged into the legal system and facing a licensing board complaint. If she had known or recognized the custody contentiousness, she might have limited her recommendations to those aimed strictly at the classroom.
Ms. Sustenance may well believe that her treatment plan will benefit Wendy, but does this mean that she is free to proceed without considering the potential cost to Wendy and/or the accused? On one hand, this type of treatment could reduce Wendy’s credibility as she may seen as having changed her story, and a guilty perpetrator may go free. On the other hand, it could mean that the defendant receives a more severe punishment than he otherwise might have gotten because of Wendy’s “enhanced” or more vivid post-therapy account of events and consequences.
Ms. Wounded seems to have done the right thing in reporting suspected child abuse, and her wish to help her young client seem well-intentioned. However, a considerable body of literature addresses the biases that can influence therapists in ways that have the potential to alter children’s memories (Ceci & Bruck, 1995; Walker, 2002). When a criminal case is pending, conducting therapy with an alleged victim requires special sensitivity as described by Branaman and Gottlieb (2013).
Dr. Danger seems in the midst of several ethical role conflicts. Even if one assumes that his diagnoses and treatment plans are competent, he must recognize that his work will have forensic implications and that he should adhere to rigorous evidence-based assessment standards. He must also consider the expectations of clients and clarify these in advance. For example, suppose he treats a client and determines after a few sessions that no significant trauma damages exist. How will the client feel when his/her therapist fails to become their advocate at trial. This is one reason why therapists should always avoid agreeing to take on roles as forensic evaluators for their clients. In addition, by agreeing to defer billing until cases are settled Dr. Danger recognizes that he has a role in the legal case and at the same time seems blind to his financial interest in the outcome.The practical message inherent in all such cases involves a role shift into the forensic arena. Attorneys seeking out the services of mental health practitioners will generally have their own clients’ advocacy needs at the top of their agenda. As a result, the practitioner should pause and enlist a consult from a colleague skilled in forensic work whenever their role might involve a forensic facet or shift.
Touch is an intensely intimate, complex mode of communication that can convey support, consolation, empathy, caring, and sincere concern. Yet, touch has several faces. It can also signal sexuality, anxiety, aggression, and even fear. The relationship between the “toucher” and the “touchee,” and how each party experiences the other’s touch, can create complicated ethical dilemmas between client and therapist.
Historically, the “laying on of hands” has been an integral part of the healing process. Modern-day science has repeatedly demonstrated the calming and attendant physical benefits of supportive stroking. It would seem, then, that touching should be an integral procedure in mainstream psychotherapy. Touching clients, however, demands considerable caution that takes many factors – such as age, personal touch history, gender, therapeutic orientation, client presenting problem diagnosis and experience, culture and class, and context – into consideration (Celenza, 2011; Zur, 2007).
When therapists do touch clients, the circumstances most frequently listed as appropriate, include expressions of emotional support and reassurance, and during the initial greeting or closing of sessions. Very brief non-erotic touching on the hand, back, and shoulders are the safest areas of touch while still conveying a caring, supportive message (Wilson, 1982).
Early surveys revealed that a majority of psychologists and psychiatrists never or rarely engaged in non-erotic touching (Holroyd & Brodsky, 1977; Kardener, Fuller, & Mensh, 1973). Subsequent surveys suggested that non-erotic touching of clients had begun to increase. Stake and Oliver (1991) reported reasonably high rates of touching of the shoulder, arm, and hand and hugging by both male and female therapists with both male and female clients. Average rates were highest for women therapists and their female clients, and these touching behaviors were rarely viewed by the survey respondents as constituting misconduct. Similarly, the majority of respondents in the survey by Pope, Tabachnick, and Keith-Spiegel (1987) reported “sometimes” or “often” hugging clients or shaking their hands. The prevailing attitude seemed that both of these behaviors proved acceptable under most circumstances. Kissing clients on the lips or cheek occurred less often and would more likely qualify as unethical.
More recent work suggests a return to greater caution regarding touching clients. Stenzel and Rupert (2004) found that 90% of their national survey sample never or only rarely touched clients. A handshake upon entering or exiting the session ranked as the most common tactile event. Successful lawsuits against therapists charged with sexually-motivated touching and sexual harassment may have chilled any form of touching beyond traditional formalities.
At times, clients may unexpectedly initiate a desire for physical contact with their therapists, and a decision to touch or not to touch must occur on the spot. Consider this dilemma, some version of which most therapists will face at some point:
Ivy Holdme, a divorced mother with custody of two difficult children experiencing serious troubles at school, had her car stolen the previous day. At the close of a dreary session, the mother said to the therapist, “I really need a great big hug.”
Although the nature of the already-established relationship will play a large role in the therapist's response, several questions will still come to mind. Should I do it? Would it affect our therapeutic relationship? What kind of a hug should it be – short or long, tight or limp? The therapist's level of comfort with touching and being touched will also come into play (Kertay & Reviere, 1993). Therapists who recognized their own physical attraction towards a client must exercise extra caution. If the client has already indicated clear signs of sexual attraction toward the therapist, engaging in any physical contact is ill-advised.
The following case illustrates how vastly differing perceptions of touch can lead to ethical charges.
Janet Demure complained to an ethics committee that her therapist, Pat Stroke, Psy.D. behaved in a sexually provocative manner, which caused her considerable stress and embarrassment. He allegedly put his arm around her often, massaged her back and shoulders, and leered at her. Dr. Stroke felt shocked upon learning of the charges and vehemently denied any improper intentions. He claimed that he often put his hand briefly on his clients’ backs and patted or moved his hand with the intention of communicating warmth and acceptance. His customary constant eye contact was his way to communicate that clients had his full attention. He admitted that Demure seemed uneasy, but expected this would quickly pass as it did with others unaccustomed to expressions of caring.
Dr. Stroke’s training as a humanistically-oriented practitioner disposed him toward nonerotic touching of clients (Durana, 1998). Regardless of therapeutic orientation, it is necessary to remain aware of individual clients and their special needs and issues, a sensitivity that may well require an alteration in one's usual demeanor. Cultural factors surrounding touching another must also be taken into account (Sommers-Flanagan, 2012).
Because such issues may catch therapists completely off guard, wise practitioners will carefully consider these eventualities in advance. Not wanting to appear rejecting may overtake the moment, but a knee-jerk compliance with the request could have consequences, even if for only a small percentage of clients. For some clients, any form of touching under any circumstances can feel inappropriate.
Ava Batter, who has suffered recent physical abuse by her husband, began to cry and shake uncontrollably after recounting her torment during her initial session with Holden Pity, M.A. Mr. Pity’s words could not console her. He went to her chair, knelt down, and put his arms around her while rocking gently. Mrs. Batter did not return for a second session.
Ethically, this challenging situation pitted compassion against good professional practice. Because it occurred during the first session, Mr. Pity did not know his client well enough to have a full awareness of her physical boundaries. He should have exercised more caution, especially given his knowledge that she had experienced physical abuse.
Finally, we acknowledge that a “no touching policy” will not guide every situation. For example, it might seem that holding a patient's hand throughout an initial session would be exceptionally inappropriate. However, consider the next case:
Irving Flexible, Ph.D. was called to consult on the case of a 23-year-old woman with severe lung disease secondary to cystic fibrosis. After introducing himself to the patient and sitting in the chair at her bedside, the psychologist asked how he could be helpful. The young woman, who had great difficulty breathing despite wearing an oxygen mask, gripped his hand tightly and said, “Don't let go.” Between attempts to catch her breath, she spoke of her terror at sensations of suffocation and the thought of dying alone.
Occasionally, variations from the usual rules constitute the highest standard of care. Deviations, however, should only occur when the following question can be answered in the affirmative – “If my colleagues knew what I had done, would they very likely agree that I served only the needs of my client?” Dr. Flexible easily passes that test.
Are therapists who touch and kiss clients also more likely to have sexual relationships with clients? Sexual activities usually start out slowly as intimate relationships progress. Holroyd and Brodsky (1980) found that those therapists who admitted having sexual relationships with their clients also advocated and engaged in more non-erotic touching of the opposite sex, but not same sex, clients. The authors conclude that non-erotic touching is predictive only when the therapist is selective about the gender touched. Other surveys have found a relationship between nonsexual multiple role relationships and sexual boundary crossing (Borys & Pope, 1989, Lamb & Catanzaro, 1998).
Based on surveys conducted over past quarter century, we feel confident in predicting that almost every therapist will face at some point in his career erotized stirrings in the context of executing professional responsibilities. The emergence of such feelings is a function of human nature; the way we manage those feelings lies at the heart of ethical professionalism. Unfortunately, we don’t talk about it as much as we should in both training and professional discourse (Pope, Sonne, & Greene, 2006).
As with most typical human courtship rituals, sexual relationships between therapists and their clients often reveal similar progressive phases – feelings of attraction, mild flirtation, some friendly touching on “safe” body areas, a cup of coffee at the café across the street from the office, a switch in the client’s schedule to the last appointment of the day, hanging around afterwards to talk about things in general, and hugging good-bye. Any sexual act often seems the culmination of a process occurring over time, starting with vague, uneasy feelings of excitement, but progressing in tidy, rationalized steps.
Feelings of sexual attraction require neither physical expression nor disclosure. They can remain one's own little secret and, most of the time, cause no real harm. So, perhaps it surprised no one when the first published survey on sexual attraction in therapy discovered that therapists who reported they had never felt attracted to any of their clients fell in a distinct minority (Pope, Keith-Spiegel, and Tabachnick, 1986). Despite the high rates of attraction, however, a much lower percentage of psychologists (9.4% of the men and 2.5% of the women) reportedly allowed the attraction to escalate into sexual liaisons with their clients. Another survey (Rodolfa, Hall, Holms, et al., 1994) found that only 12% of their large sample of APA members reported never having felt attracted to a client, only a few had ever acted on these feelings, just less than half reported negative consequences, and over half sought consultation. Pope and Tabachnick (1993) reported that almost half of the therapists responding to their national survey had experienced sexual arousal during a therapy session.
Under what conditions should feelings of attraction become cause for concern? How should one handle such feelings? If a therapist finds attraction occurring often, should one seek outside consultation? In an interview study with postdoctoral interns, most participants admitted to behaving in a more invested and attentive manner to those clients to which they felt attracted, but that the attraction also caused them to become more easily distracted and less objective (Ladany, O’Brien, Hill, et al., 1997). Because the therapy process may be compromised, it seems regrettable that only half of the sample in this study reported disclosing their feelings to their supervisors.
When therapists cannot bring their feelings under control or sense their feelings are having an adverse effect on how they treat their clients, and when consultation is sought but was ineffective, we recommend a sensitive termination and referral as a way to protect all parties from complications, confusion, and harm. The therapist might say something like, “I would recommend that you work with someone more skilled than I am in addressing the issues of concern to you.”
When a therapist senses even a small attraction toward a client, we strongly recommend against ignoring it. We offer a dozen alerts, any of which would indicate that the attraction feelings may tend to put you and your client at potential risk, or that your processing may suffer a loss of objectivity and thereby risk reduced competence.
Therapists may experience surprise, and even shock, to recognize that they have sexual feelings toward a client (Pope, Sonne, & Holroyd, 1993). Should one discuss such feelings with the client? Some have debated the issue, but, after considering the available evidence, we would not recommend it (See Fisher, 2004). The client may not be able to deal with a frank admission of the therapist's attraction and may become confused, uncomfortable, and unclear about how to respond. In addition, such disclosure injects the therapist's own issues into the client's life in a way that constitutes poor professional practice. A client might perceive such revelations as harassing or even repulsive. Finally, the intrigued client may readily interpret the revelation as an invitation to follow the therapist's lead outside the office, which may not (and should not) be the therapist’s intent.
When professional vision becomes distorted, excuses to make moves that may later be deeply regretted seem to flow all too easily. We strongly advise therapists to discuss lingering attraction feelings towards a client with someone, preferably another therapist, an experienced and trusted colleague, or an approachable supervisor.
At first blush, client sexual attraction to therapists does not belong in a high risk category. However, as we shall illustrate, unless such client feelings are handled carefully, the result can be damaging to all concerned. That clients would be sexually attracted to their therapists comes as no surprise, given the emotionally intimate nature of psychotherapy. Rather than use the term transference, Parish and Eagle (2003) prefer the term “attachment” which manifests itself in clients perceiving therapists as emotionally responsive, admirable, a secure base, unique, and irreplaceable. Such powerful feelings can readily cause love, or something like it, to surface. In a national survey of female psychologists, almost half reported potentially sexualized behavior emanating from their male and, less often, female clients (deMayo, 1997).
How should therapists respond to clients’ declarations of attraction? If a client openly and directly expresses erotic feelings, it is important to deal with these impulses in a way that both preserves professional boundaries and protects the client's self-esteem. Leaping into interpretations of unconscious issues may feel like the safe way to go, but could feel humiliating by the sincere client who has just who mustered up the courage to disclose innermost emotions. A therapist's too-fast declaration that acting on any such feelings would be unethical and unprofessional may come across as an anxious overreaction. In addition, therapists must remember that when a client directly expresses erotic feelings it does not necessarily mean that the client expects them to be acted upon. What the therapist interprets as seductive behavior could be, instead, an indicator of dependency.
We suggest that whenever a client makes any request or disclosure where reciprocation would be inappropriate, first ask that client how they see the fulfillment of the request as being helpful to them. Then, follow with a discussion about why granting the request would actually not be in their best interests. This way the focus remains solely on a caretaking orientation. If a client becomes aggressively seductive, Gutheil and Gabbard (1992) suggest a more unyielding approach – tell the client that therapy is a “talking relationship,” and discuss why the client's behavior is inappropriate.
Rarely a patient acting out exceptionally strong sexual or romantic interests may not be containable. This drastically limits the kinds of interventions available to that therapist (Ogden, 1999). In such circumstances, the best course of action is to refer the client to another therapist.
Edie Tsunami’s therapy with Tyler Engulfed, Ph.D. proceeded without incident for the first few sessions. Soon, however, Ms. Tsunami became belligerent, demanding that the Engulfed hold her hand throughout the sessions and then wanting to sit on his lap during the entire therapy hour. She cried and flailed about uncontrollably whenever Engulfed attempted to get her back into a chair. The demands accelerated and became more bizarre, including insisting that Engulfed watch her masturbate and that he have sex with her to simulate a rape that she allegedly endured as a child.
Although the actual therapist on whom we base this case never engaged in sexual relations with his client, he endured a highly publicized licensing hearing resulting in sanctions for continuing to treat a client whose pathology fell well beyond his level of therapeutic competence.
Giving a client a dozen red roses, taking a client to dinner or for a drink at happy hour, or staying after hours in the office to chat while listening to music do not qualify as “sexual intimacies.” Such activities, however, would, under normal circumstances, would be a superimposition of inappropriate activities on a therapeutic relationship. Casual social excursions outside the office become especially risky because they typically involve more self-disclosure on the part of the therapist and other behaviors that could easily be perceived by clients or students as courtship/dating rituals. Even if therapists had no motivations beyond platonic pleasantries, clients can become confused.
Norman Breakup, L.M.F.T., felt lonely after a bitter divorce. He missed his teenage children and the companionship they provided. He began to single out several younger male and female clients on whom to shower extra attention, alternating among them for one-on-one experiences. Sometimes, he would sit and talk for up to 3 hours after a session. He often took them out to lunch and, sometimes, shopping afterward for gifts. Breakup felt shocked when one of the women complained to a licensing board that he “wined and then two-timed her.”
Whereas we may empathize with Mr. Breakup’s personal circumstances, he exercised extremely poor judgment in treating his clients as surrogate children. Using one's client base as a population of convenient intimacy is both unprofessional and unethical. The next case reveals a much more common scenario.
Simon Inchworm, Ph.D. felt attracted to Selma Receptive, his client of several months. Selma readily accepted what Inchworm believed at the time to be a professionally appropriate invitation to attend a lecture on eating disorders, given that Selma's sister had a history of anorexia nervosa. The lecture concluded at 5 P.M., so Inchworm invited Receptive to stop for a bite at a nearby deli. The next week, Inchworm accepted Receptive's gift of a book written by the speaker they had heard the previous week. The following week, Inchworm agreed to a reciprocal dinner at Receptive's place. Afterward, while enjoying a third glass of wine, they looked into each other’s eyes, embraced, kissed for a while, and retreated into the bedroom.
It does not take a rocket scientist to predict such an outcome. In this actual case, an affair persisted for a few weeks. In the meantime, “Dr. Inchworm” met someone else of more interest to him and terminated the affair. When “Ms. Receptive” became upset, he also terminated her therapy. The client sought and won a large damage award through a civil malpractice complaint.
We believe that the most damage to clients as well as to therapists themselves occurs when a professional relationship turns into an affair. Furthermore, it appears to be the most frequent specific cause for disciplinary action (Kirkland, Kirkland, & Reaves, 2004). Sexual intimacies (usually implying intercourse but left open for other sexual physical acts) with therapy clients are forbidden in all current ethics codes issued by the primary mental health and counseling professional associations.
Although data collection lacks the rigor demanded by traditional scientific methods, available evidence confirms that sexual activity with clients will likely prove exploitative and harmful due to abuse of power, mishandling of the transference relationship, role confusion, and other factors. Ironically, therapists can suffer serious harm as well. The extent of the devastation – which can include loss of a job, license, spouse and family, financial security, and reputation – is typically far more pervasive and devastating than the fallout from committing other types of ethical transgressions.
How common are sexual relations between therapists and ongoing clients? Self-report surveys clearly indicate, even if we assume that none who did not return their survey forms had sexually intimacies with their clients, that far more therapists engage in sexual behavior than is reported to ethics committees and state licensing boards (e.g., Parsons & Wincze, 1995).
Early survey data indicated that an average of about 10% of male and 2% of female therapists acknowledged having engaged in sexual intimacies with their clients with no significant differences across psychiatry, social work, and psychology in the rates of self-reported sexual relationships (Borys & Pope, 1989). Some more recent self-report surveys offer signs that fewer numbers of therapists are engaging in such behavior with clients, students, and supervisees (Lamb & Catanzaro, 1998; Lamb, Salvatore, Catanzaro, & Moorman, 2003; Pope, 1993, 2001), although the rate may still reach an unacceptable 5 to 6%.
We can hope that the downward trend in self-report studies reflects a true shift and mirrors the influence of the absolute condemnation of sexual misconduct by the mental health professions. However, that same impact may also result in underreporting on surveys. Consumer complaints have increased, causing therapists to fear detection and litigation. Earlier, while professional communities mostly ignored the problem, clients may have felt too powerless to protest or, if they did complain, were discounted as delusional, subject to fantasy, and struggling with their transference neuroses (Barnhouse, 1978; Schwendinger & Schwendinger, 1974).
Some clients may actively and knowingly contribute to the creation of a sexually tempting atmosphere. Those with borderline or histrionic personality disorders have been especially singled out as potentially seductive (Gutheil, 1989; Notman & Nadelson, 1994). In interviews by Somer and Saadon (1999), almost one quarter of clients who admitted to having sexual relations with their therapists also admitted that they initiated the first embrace. Therapists, however, bear the responsibility to resist acting on their feelings of reciprocal attraction. Ethics committees and other hearing panels are unmoved when therapists whine that they are the ones who were lured and snared as defenseless victims of beguiling clients.
Hap Bowlover, Ph.D. wrote a letter in response to an ethics committee inquiry, insisting that he had become systematically “worn down by a client who showed up for therapy sessions wearing dresses with the neckline and the hem almost meeting and started flirting with me the minute she walked into my office.” He declared that she set a trap for him and that he was being used as a symbol for “all the men who had messed her up in the past.” He likened the client to a black widow spider and claimed to have contacted a lawyer for the purposes of suing her.
Such excuses are heard more often than you might think. Some commentators have expressed sympathy toward therapists, who, as Wright (1985) contended, find themselves enticed into lustful moments by unscrupulous clients seeking to exploit the vulnerability of therapists to their own economic advantage. Many clients who appear to encourage a sexual relationship with their therapists, however, may be repeating eroticized behaviors as learned remnants of sexual abuse from their childhoods. Such clients remain subject to re-victimization because they differ from others who may find the therapist sexy or develop an erotic transference (Kluft, 1989). Nevertheless, the bottom line remains – shifting blame or responsibility to the client, even if the client acts adeptly manipulative or seductive, never qualifies as an excuse for incompetent and unprofessional behavior.
The available data on harm to clients do not represent all client-therapist sexual liaisons because they consist only of reported instances. The majority of disclosing clients assessed from these populations report sex with therapists as damaging (e.g., Bates & Brodsky, 1989; Disch & Avery, 2001; Feldman-Summers, 1989; Kluft, 1989; Pope, 1990b, 2001; Pope & Vetter, 1991). Some clients may view the experience as pleasurable at the time, but come to view it as exploitative later (Somer & Saadon, 1999).
While serving on ethics committees, we saw the manifestations of such feelings. The complainants typically expressed outrage, described the destructive impact on other relationships in their lives, expressed feelings of abandonment, exploitation, and hopelessness, questioned whether they could ever trust another therapist again, and often stated that they pressed charges chiefly to make sure that what happened to them would never happen to anyone else.
Perhaps because of the especially serious professional, personal, and legal consequences that accompany sustained charges of sexual misconduct, the research on incidence and harmful impact on clients has come under attack (e.g., Williams, 1992). Sampling, response and experimenter biases appear as common criticisms of such research. Others have objected to the assumption that harm automatically accrues as a result of having sex with a client, or that an adult client lacks competence to consent to having sex with whomever he or she chooses (Slovenko, 1991). Although one can quibble about the quality of research and the generalizability of the findings, such debates obscure the basic point – sex with clients is unethical and lies far outside accepted standards of care. As Behnke (2006) observes, sexual involvement with clients renders psychotherapy impossible, and deriving this kind of gratification while conducting a fiduciary duty does not qualify as legitimate.
Sexually exploitative therapists portrayed in films often seem dashing, debonair, and self-assured. These depictions hardly reflect the portrait emerging from the available information about real therapists who engage in sexual activity with their clients. Instead, we know that sexualized relationships with clients can not only cause substantial harm to the individuals involved but also to the relationships of those involved (Sonne, 2012).
Although data about therapists who sexually exploit their clients lack the scientific rigor of a controlled experiment, available reports suggest that therapists who engage in sexual intimacies with clients have significant personal issues. These include general feelings of vulnerability; fear of intimacy; crises in their own personal sex, love, or family relationships; feelings of failure as professionals or as individuals; high needs for love or affection, positive regard, or power; poor impulse control; social isolation; overvaluation of their abilities to heal; isolation from peer support; sexual identity and other unresolved conflicts; depressive or bipolar disorders; and narcissistic, sadistic, and other character or predatory psychopathologies (Butler & Zelen, 1977; Gabbard & Lester, 1995; Hetherington, 2000; Lamb, Salvatore, Catanzaro, & Moorman, 2003; Marmor, 1972; Olarte, 1991; Pope, 1990a; Solursh & Solursh, 1993). Offending therapists tend to excuse their behavior (Celenza, 1998), and they work alone (Somer & Saadon, 1999). They often deny to themselves that their behavior has an adverse impact on clients (Holroyd & Bouhoutsos, 1985), and seem deficient in their ability to empathize (Regehr & Glancy, 2001). Most relationships apparently do not last long, and, about half the time, are later judged by the clients as not worth having (Lamb, Salvatore, Catanzaro, & Moorman, 2003).
Prototypical offenders remain males in their 40s or 50s (Bates & Brodsky, 1989; Butler & Zelen, 1977; Notman & Nadelson, 1994; Sonne & Pope, 1991). The middle-aged therapist going through a divorce or having other problems in a primary relationship should remain alert because their risk of over-involvement with clients runs especially high (Twemlow & Gabbard, 1989). Some abusing male therapists may have themselves experienced sexual abuse as children (Jackson & Nuttall, 2001).
Clients exploited by their therapists are mostly younger women. Perhaps as many as 5% are minors at the time of the sexual activity, and almost a third qualify as victims of incest or physical abuse as children (Pope & Vetter, 1991). A homosexual client of either sex with the same-sex therapist seems the next most frequent category, although a distant second (Bates & Brodsky, 1989).
Female psychologists have a lower rate of engaging in sex with clients than do male therapists. The reasons for this remain the subject of debate in the absence of solid data. Perhaps female sex roles have allowed women to learn and practice a spectrum of techniques that do not involve sexuality for communicating love and nurturance. Maybe traditional cultural conditioning of women to refrain from taking the sexual initiative has also taught them better control of sexual impulses as well as techniques for resisting sexual advances. When female therapists become respondents in ethics hearings or civil suits over sex, the complainants will likely be lesbian clients or the wives, partners, or family members of the men with whom the therapists allegedly had sex.
Complaints by males against their female therapists remain rare but are no longer anomalies (Pope, 2001).
We know little about the effect on male clients of sexual experiences with their female therapists. Slovenko (1991) suggests that it never occurs to the male client, even in litigious times, to sue a woman for having had sex with him. Some have even suggested that men would welcome such advances by their female therapists and perceive them as esteem building. However, a colleague who has treated several male clients in the aftermath of harm caused by engaging in sexual relations with previous female therapists informed us that men do not make formal complaints because they fear a response of ridicule.
Only the rare case seems driven by a therapist’s mean-spirited, premeditated attempt to exploit, such as the counselor who hypnotized clients for the purpose of getting them to masturbate in his presence or the psychologist who had sexual relationships with three of the most intriguing of his dissociative client's 16 personalities. Most societies condemn coerced sex, and thankfully, such acts involving therapists and their clients are apparently exceedingly infrequent.
A more frequent but equally abhorrent scenario involves attempts by the therapists to either consciously manipulate or rationalize sexual activity as a legitimate feature of the therapy. Therapists in this category manage to convince themselves that they have acted in a genuinely charitable manner by giving clients something special to alleviate their problems. Rescue fantasies also commonly come to the fore in this group (Notman & Nadelson, 1994), with such therapists having little insight into the self-serving nature of their actions.
We know of cases where the therapists invented techniques built around sexual exploitation. Such cases remain very rare, but highly visible because they attract media exposure.
Blunt Force, Ph.D. performed his “Soma Release Therapy” on scores of women before losing his license. He claimed that having his client wear flimsy robes while he put extreme pressure on their genitals and breasts would release suppressed emotions.
Such rare but creepy perversions of psychotherapy appear to represent attempts to satisfy the therapist’s own peculiar proclivities without any regard for the clients' best interests. The real Dr. Force attempted to explain the theory behind his therapy method to an ethics committee, but it involved little more than twisted psychobabble.
Another high profile lawsuit, from which we adapted the next case, reveals a wicked use of drugs that was not, in our opinion, appropriately decided.
Maxwell Comatose, M.D. treated over 200 women presenting sexual problems by drugging them with a potentially dangerous relaxant and then encouraging them to become sexually aroused in his presence. Sometimes he would touch them on their breast or genitals to stimulate them before commencing a guided imagery exercise during which his patients simulated sexual interaction.
The psychiatrist in the actual case was tried for indecent assault based on eleven complaints, but won acquittal based on his claim of having their informed consent. He suffered a brief license suspension, yet was soon allowed to resume practicing so long as he did not use this particular technique.
The male therapists who initiate intimate relationships with younger females may seek “as if” intimacy or recaptured youth and virility. Dr. Sorry is typical.
Samuel Sorry, Ed.D., a counselor in his late 40s, explained to an ethics committee that a series of rapidly accelerating crises in his personal life had triggered his sexual relationship with a 26-year-old client. His wife of 25 years left him for a woman, his son abused drugs, and his father recently died. He felt lost and saw himself as a failure. His young client seemed trusting and complimentary, and, in his exact words, “`She was the only thing [sic] in my life that I looked forward to.”
The first sign of deterioration after the relationship becomes more actively sexualized usually occurs when the client expresses a wish to extend the relationship and deepen the commitment between the two of them. At this point, most therapists (especially those who are married or in a committed relationship) react with some form of distancing. Whether a response to fear, guilt, delayed moralistic stirrings, disinterest, or a belated recognition that they have committed serious therapeutic errors, clients often experience such withdrawal as rejection and abandonment. The angered clients may seek redress.
A fair number of offenders appear to believe that transference-like feelings do not result from therapy dynamics but, rather, emanate from clients’ genuine attraction to them as persons. They convince themselves that the clients would have the same reaction to them had they met casually in another setting under different circumstance. Rescue fantasies that some therapists attach to their clients’ idealization of them often complicate the profile (Folman, 1991). Here a perilous “fairy tale” dimension gets interjected, with the therapists seeing themselves as heroes who will create happily ever-after endings.
Therapists who enter sexually intimate relationships with clients may attempt to excuse their sexual involvement believing it flows from heartfelt love. Gartrell, Herman, Olarte, Feldstein, and Localio (1986, 1989) report that 65% of offenders stated that they were in love with the patients they bedded.
Compared with the other offenders, this one may evoke some degree of sympathy. Falling in love (or becoming infatuated) with a client, however, does not excuse a therapist from professional responsibility. Twemlow and Gabbard (1989) and Gabbard and Lester (1995) describe the lovesick therapist unsympathetically as a narcissistic, emotionally dependent individual who enters an altered state of conscience when in the presence of the special client, which then impairs judgment in that case, but not necessarily for others. The state of lovesickness may reduce feelings of guilt because the therapists become convinced they can provide quality therapy and that their motives are honorable; such therapists lack insight into the potentially destructive nature of their behavior.
Should a therapist and a now ex-client feel “ethically free'” to commence a sexual relationship after therapy has concluded? Why should consenting adults in our democratic society not have the right to decide with whom they wish to consort? After all, client autonomy stands as a primary goal in therapy. As Bersoff (1994) contends, “Society in general and our professional association [American Psychological Association] in particular should remain committed to… respecting each individual's right to choose his or her own fate, even if the choices the individual makes do not serve…what the majority would consider to be in the individual's best interest” (p. 382). On the other hand, do other potential perils lurk for an indefinite period after termination of the psychotherapy relationship?
Entering into sexual and even marital relationships with former clients is not that uncommon. Taken together, available survey data indicate that between 3% and 10% of the respondents have sex with former clients (e.g., Borys & Pope, 1989; Lamb, Catanzaro, & Moorman, 2003; Lamb, Strand, Woodburn, et al., 1994; Pope et al., 1987, as cited in Pope, 1993). Less than half of the psychologists in Akamatsu's (1988) survey judged sex with ex-clients as a serious ethical problem.
We will use the American Psychological Association (APA, 2010) as the example for how the ethics code regarding sex with previous clients evolved. (However, we note here that the American Association of Marriage and Family Therapy (2012) and the National Association of Social Workers (2008) have taken a very similar path.)Before 1992, the ethics code of the APA was silent on the question of sex with clients after an appropriate termination of therapy, as were most state boards and ethics committees (Sell, Gottlieb, & Schoenfeld, 1986). Ethics committees could pursue charges prior to 1992 when a complainant made a compelling argument that therapy ended irresponsibly and some form of harm resulted. However, substantiating or denying botched terminations proved difficult at best.
In 1992, the APA ethics code revision team confronted for the first time the issue of post-termination sex with clients. After lengthy debate about how to frame a prohibition, they created a 2-year post-termination moratorium clause, placing clear limitations in the short run. At the same time, they opened the opportunity for sexual relations between ex-therapists and ex-clients without professional repercussion at some future time. The code did not unconditionally condone eventual liaisons with clients. Additional provisions warned the psychologist that sexual intimacies with former clients would likely prove harmful and undermine public confidence in the profession. Thus, the psychologist who enters into a sexual relationship with a former client after two years would also bear the burden of demonstrating absence of exploitation in the event of a complaint. The 1992 APA code also listed considerations that one should carefully weigh before embarking on sex with a former client. Time passage since termination stood as the primary consideration, with a presumption that the longer the delay the lower the ethical risk. Other considerations included the client's current mental status and degree of autonomy, type of therapy, how termination occurred, and what risks may still present themselves if a sexual relationship commenced. Thus, the complaints described in the next case would be heard by an ethics committee, despite the fact that the minimum period of two years had passed before sexual activity occurred.
Upon termination of four years of psychotherapy, Mattie Stringalong, Ph.D. suggested that she and Lenny Endure keep in touch. They started exchanging cards and letters, spoke on the phone almost every week, and occasionally met for lunch. After 20 months, Dr. Stringalong informed Endure that their relationship could become sexual soon. They eventually married. Endure asked for a divorce a year later, also complaining to a state licensing board that Dr. Stringalong had been “laying in wait” so that she could get her hands on his substantial family fortune.
Here, the sexual activity occurred in the “correct” time frame, but the therapist kept an uninterrupted relationship afloat. Even if Dr. Stringalong were not guilty of plotting to gain financially, her active perpetuation of an emotionally charged relationship quickly after termination was unethical. The 1992 APA code also defined as unethical any statements or actions on the part of the therapist while therapy was active that suggested or invited the possibility of an eventual relationship with a client.
The next case illustrates a therapist’s comment just after termination that would still constitute an ethics violation.
When Geraldo Futura, M.A., and his client Cecelia Sanguine tentatively acknowledged a mutual attraction, Futura allegedly told her that, because of professional ethics, they would not start an affair because he would get into “big trouble.” However, during the last session, Futura winked and said in a soft voice, “Give me a call in a couple of years.”
An ethics committee would not view this sort of termination as appropriate. Futura’s parting words set up an expectation that significantly altered how the therapeutic experience will be remembered by the client. So, what kind of post-termination relationship might be ethically acceptable? The next case, revealing a chance meeting years later, would not likely cause an ethics committee concern.
Vasti Shamoo signed up with Slim Downe, Ph.D., for a weight reduction program that used behavioral techniques. Ms. Shamoo lost her goal of 12 pounds in 4 weeks, and the sessions were terminated by prior agreement. Three years later, Shamoo and Dr. Downe found themselves face to face at a party. Shamoo had to remind Downe of their past work together. They talked for a while, learned that each was free to date, and started seeing each other regularly.
When it came time to revise the APA ethics code in the late 1990s, concerns were raised about the two year moratorium provision. An Ethics Code Task Force proposed that the prohibition of sex with clients should exist in perpetuity (Martin, 1999). However, the most recent revision (2010) is almost identical to the 1992 version, with a section discussing proper termination added. Still, questions remain unanswered. Does knowledge, on the part of the psychologist or the client, that a post-termination sexual involvement is possible, affect the service provided? Under what circumstances do post-termination sexual relationships result in harm? Are individuals able to exercise a truly autonomous choice to enter into sexual involvement with a former treating psychologist? (Behnke, 2004). Research has yet to definitively answer these important questions.
We have concerns about condoning post-termination sexual relationships, even with stated conditions. Anyone who has felt extremely attracted to another person knows that one cannot mask passion for long. Data suggest that well over half of the post-termination sexual liaisons between therapists and their clients began quickly, within the first 6 months (Gartrell et al., 1986). If being together is not permissible, however, both parties would typically go their own way and find other sources to satisfy their needs.
We have additional doubts about the advisability of instituting the 2-year “cool off” moratorium. Our main concern is that the APA stand on post-termination sex has the potential to alter the therapy relationship from the onset (also Gabbard, 1994; Gabbard & Pope, 1989). If clients feel attracted to their therapists (a common occurrence) or therapists feel attracted to their clients (also common), and aspire to a different kind of relationship down the line, how likely are either to do or say anything that will put them in an unbecoming light during active therapy? Would what was said during sessions constitute psychotherapy, or primarily a long-term investment in a potential future relationship?
We must also note that a therapist’s professional responsibilities do not conclude at termination. Continuing client rights to privacy, confidentiality, and privilege remain unaffected by therapy termination. The possibility of a subpoena of records and resulting court appearances also exists (Gabbard & Pope, 1989). As a result, clients could find themselves severely disadvantaged should they have need of professional services from a therapist who has become a lover (or ex-lover).
Donald Reprisal, M.A., and his ex-client, Alka Hollick, were married two and a half years after therapy terminated. They had a child the next year, and divorced a year after that. During a bitter custody battle, Mr. Reprisal raised his wife’s previous alcohol addiction, her sexual escapades prior to their marriage, as fitness issues.
Therapists need to remain responsible for any continuing duties and carry them out free from any conflict and role confusion that a sexual relationship imposes. Mr. Reprisal used knowledge originally gained in confidence to the disadvantage his wife who was also a former client.
Perhaps the most controversial aspect of APA’s 2-year moratorium provision is the implication to the public that sex with one's therapist remains a viable possibility, as do the codes for social workers and marriage and family therapists. The National Association of Social Workers, for example, prohibits sexual relationships with ex-clients, but does allow a wiggle space for “extraordinary circumstances” requiring the social worker to “assume the full burden of demonstrating that the former client has not been exploited, coerced, or manipulated, intentionally or unintentionally” (NASW, 2008). Counselors have similar requirements regarding exploitation, but require a 5 year moratorium (ACA, 2005). The American Psychiatric Association, on the other hand, has issued a clear message to the public, voting in 1992 to declare sex with former patients unethical in perpetuity (American Psychiatric Association, 2013).
Little has appeared in print specifically about sexual involvement by therapists with the sisters, brothers, guardians, adult children, parents, or very close friends of current psychotherapy clients. The APA ethics code (2010) disallows psychologists from entering into therapy with such known persons and forbids using termination of therapy as a way of circumventing compliance. Similarly, the NASW code (2008) mandates that social workers refrain from sexual activities or sexual contact with clients’ relatives or other individuals with whom clients maintain a close personal relationship when a risk of exploitation or potential harm to the client is possible. The ACA code (2005) takes the strongest stand against sexual relationship with clients’ significant others. Counselors are not to engage in romantic or sexual contact with the romantic partners or family members of current or former clients for a period of 5 years. Even then, the burden remains on counselors to document that no exploitation occurred. (As of this writing, the American Association of Marriage and Family Therapists and the American Psychiatric Association do not specifically cover sexual relationships with significant others in their ethics codes. However, admonitions against exploitation could apply to such situations.)
A client abruptly terminated therapy and complained to the state licensing board upon learning that Rob Cradle, Psy.D. has “slept with my baby girl.” Although the daughter was 25 years old, the parent-client felt betrayed by Dr. Cradle. The client assumed that Cradle had shared everything she'd said in therapy with her daughter, and maybe they even shared laughs at her expense after they made love.
In this case, the therapist knew at the onset of the romantic relationship that his current lover was the daughter of an active client. He erroneously reasoned that because the daughter did not have client status and because the two were consenting adults, no ethical obligation pertained. However, it should have been obvious to Dr. Cradle that the ethic admonishing therapists to refrain from entering into any relationship if it appears that it could impair objectivity or interfere with effective therapy performance clearly applied to this situation.
Wadya Wannado, Ph.D., a clinical child psychologist, treated Billy Boyster on an outpatient basis. Billy, age 7, showed signs of an adjustment disorder in reaction to his parents' deteriorating marriage. Dr. Wannado saw Billy individually on a weekly basis for several months and met jointly and individually with his parents on three or four occasions to help them deal with Billy's problems. Soon after Billy's therapy was terminated, the relationship with Billy's mother became sexually intimate. The father filed an ethics complaint against Dr. Wannado, who responded that he had done nothing wrong because he was no longer treating Billy and the mother was never a client.
When the client is a child, it becomes therapeutically and ethically critical to consider the family as the unit of treatment. Although Dr. Wannado's clinical attention focused on Billy, the parents had legally contracted with him for professional services. In addition, meeting with the parents in any professional capacity constitutes a therapist-client relationship. Dr. Wannado owes ethical obligations to Billy and both parents equally. The fact that Dr. Wannado had ended treatment with Billy does not end his professional obligations to the boy. Even after divorce, children harbor fantasies of parental reunion. Most likely, Billy will feel ambivalent, if not outright betrayed, by the invasion of the therapist into the relationship between his parents. Dr. Wannado's conduct is particularly reprehensible as it intrudes adversely into the relationships of three people undergoing a difficult transition, all of whom were owed duties of care. Slovenko (2006) notes that clients may even have a malpractice cause of action against a therapist for "undue familiarity" and infliction of mental distress in the event of sexual involvement with a member of the client’s family.
We conclude with a brief commentary regarding the ultimate consequences of unethical behavior on therapists themselves. Facing an ethics or licensing board inquiry is intensely anxiety arousing (Casemore, 2001; Koocher & Keith-Spiegel, 2008) as well as threatening to their livelihoods (Grenier & Golub, 2009). Sanctions and directives vary, but punitive measures can destroy a career when a member is expelled from a professional association and the licensing board suspends or pulls the license to practice.
Any finding by an ethics committee must be reported to insurance panels and on HMO contracts, review boards, and other professional disclosure requests. Some note that the American Psychological Association can allow one to escape an ethics investigation by resigning from the organization. But that still doesn’t get one entirely off the hook. Besides being effectively banned by one’s professional organization, the entire membership and sometimes the public get notification of this action with no expectation of confidentiality. The notice gives no details about the charge, but most presume that the individual was guilty of something, leaving it up to the imagination as to what the infraction might have been.
A sensitive research article by Warren and Douglas (2012) offers insights into the stigma after being sanctioned by an ethics committee. Here is an excerpt from one of their care reports:
The day the letter came from the licensing Board was not unlike the day I received the call of my father’s death. Something permanently ended, the pain visceral, deep, unrelenting, and the regret of not doing things differently is unforgiving. Not only is the pain unending, the fears are immobilizing. What will others think of me? Will I lose my job? ... I wish there was a cave of solitude and safety I could escape to ... I do not want to be seen. (p. 137)
Our ethics committee experiences with psychologists found guilty of ethical infractions also reveal intense shame, guilt, anxiety, suicidal thoughts, and even onset of physical ailments, such as high blood pressure (Keith-Spiegel, 2013). Coworkers and colleagues may distance themselves from the violator (Reghr & Glancy, 2010).Of course, no one – not even those with conscious malintentions – sets out to get busted by an ethics committee or licensing board. It is clear that avoiding high risk behaviors by remaining self-aware and monitoring one’s own needs and intentions is prerequisite to avoid doing harm to clients as well as to oneself.
Most mental health professionals have the capacity to sustain appropriate professional boundaries upon which both client and therapist can always depend. Creating that safe place is the primary reason for keeping appropriate boundaries with one’s clients. However, sliding down a “slippery slope” is not always recognized until it is too late. Coupled with areas of dissatisfaction in one’s own life and rationalizations that excuse engaging in exceptions to what the violator usually knows to be competent practice, even therapists who have solid track records of exemplary work end up losing everything.
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