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High Risk Temptations and the Ethics of Multiple Role Relationships
by Gerald P. Koocher, Ph.D. and Patricia Keith‑Spiegel, Ph.D.

2 CE credits - $49

Last revised: 07/01/2010

Course content © copyright 2010 by Gerald P. Koocher, Ph.D. and Patricia Keith-Spiegel, Ph.D. All rights reserved.

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Learning Objectives

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.

Course Outline

AN INTRODUCTION TO HIGH RISK TEMPTATIONS

Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief, and in particular of sexual relations with both female and male persons, be they free or slaves.

Hippocratic Oath (ca. 400 B.C.E.)

Mental health professionals may puzzle over how intelligent, educated men and women could so foolishly engage in unprofessional and unethical behaviors that pose significant dangers to themselves and their clients. Yet it seems clear that psychotherapeutic alliances have peculiar and significant features that require particularly firm professional resolve. Twemlow and Gabbard (1989) put it bluntly; “Every psychotherapist struggles with the temptation to seek personal gratification from the therapeutic situation” (p. 71).

One might assume that the 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 high risk types of therapists and situations, we have also concluded that no one seems immune from temptation. 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 pain. 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 feels like a “great deal.” What could go wrong? The two already knew 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 an abusive 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 “taking advantage of my vulnerability and 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 one-quarter-of-sticker price at 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, the client pressed an ethics complaint charging that the therapist was only after her money and her merchandise at bargain prices.

The fourth scenario has a couple of unusual aspects in that the counselor did not know much about the client because 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 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 him and was needlessly hurt.

The final scenario may feel 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 always runs the risk that they may never have 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 the person on whom he had depended, and attempted suicide.

This lesson will focus on high risk role-blending 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, 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.

ENTERING INTO BUSINESS RELATIONSHIPS WITH CLIENTS

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 ongoing 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 ventures that have gone awry illustrate the damage done to both therapists and their clients:

No rational person goes into business unless he hopes to profit financially, which puts immediate and complicating expectations and pressures on his 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. Both 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 the licensing board. Ms. Dip believed that because Sculpt instigated the partnership and because she terminated the therapy with him, she has no responsibility for what ultimately transpired. On the contrary, the responsibility rested exclusively with her because her training should have enabled her to foresee the potential hitch in the 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 have turned on her.

ENTERING INTO PROFESSIONAL RELATIONSHIPS WITH EMPLOYEES

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, competition for promotions and resources, and disliked 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 brought 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 also works as an employee, the consequences of a multiple role relationship gone awry can be especially devastating because of the potentially adverse career and economic ramifications. Dr. Honcho should have known better than to take on Ms. Typer as a client.

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, 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.

EMPLOYING CLIENTS

Delivering mental health services to individuals who possess special skills will inevitably lead to some degree of temptation to consider what skills these clients might have to offer you. Moreover, clients feel increasingly financially strapped in this difficult economy. Offering to employ them may seem like doing 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 work 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 ridiculous. An insulted Clerk quit his job as well as his therapy, and wrote to an ethics committee claiming that Dr. Scatterbill had “ruined his whole 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 styles of interaction.

Snap Shudder needed additional work to make overdue payments on a new car. When Snap 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 and insisted that Groom not pay Shudder. In the meantime, Shudder increased the agreed-upon price because the bride’s demands caused him extra work and expense. Shudder quit therapy, told everyone in town that Groom had married a witch, and successfully sued Groom in small claims court.

That Shudder purchased a car he could not afford was not Groom’s problem to solve. Groom might have politely refused Shudder’s offer, noting that the couple had finalized their wedding plans. Even in situations where the job seems specific and time-limited, competent judgment must supersede giving into what appears on the surface a reasonable arrangement. In the meantime, Groom’s reputation in the community suffered.

Even financial dealings with clients motivated by genuine kindness can backfire. Here is another case, with similarities to one in our opening scenarios.

Barney Bigheart, Ph.D. felt sympathetic when his client Bart Busted faced foreclosure on his home. Bigheart offered to loan Busted several thousand dollars to stave off the lender. Busted gratefully accepted, and signed an unsecured note with a generously low interest rate. Busted's financial situation did not improve, however, and he failed to make any loan payments to Bigheart. Even though Bigheart exerted no pressure regarding the payments, Busted expressed considerable guilt over “letting down the only person who ever gave a damn about me.” Busted's depression deepened, and he required hospitalization.

We can hardly question Bigheart’s compassion, but we can fault his professional judgment. By attempting to solve directly his client’s financial problem, he destroyed Busted’s psychotherapeutic refuge. Simply remaining available as Busted’s caring therapist, and perhaps substantially reducing the fee or seeing him at no cost, would have far better served this client’s needs.

ACCEPTING CLIENTS’ EXPENSIVE GIFTS

Mental health professionals often receive words of sincere appreciation from their 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 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, and special dangers lurk here. Gifts have the power to control, manipulate, or symbolize far more than the recipient may 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. 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 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. A strong professional identity provides the key ingredient in dealing appropriately with gift offers.

Flashi Dresser, L.I.C.S.W., was surprised when her clothing designer client walked in carrying a magnificent gown. “I made this just for you,” said the client. Dresser loved it and made the mistake of accepting it without further thought, particularly since the client was in the middle of a messy child custody dispute and she didn’t want to upset her by refusing it. However, Dresser already knew that the client had an agenda, namely to convince her to testify that the client’s father had abused the kids. When Dresser steadfastly refused because she had no credible evidence of any abuse, the client became furious and contacted an ethics committee charging that Dresser forced her to create an expensive outfit for her.

Aside from the expense of the gown (valued at $800 in the actual case), Dresser succumbed to her own 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 her client, it did admonish her for poor professional judgment.

A grateful elderly client gave Harvey Time, Ph.D. her father’s solid gold watch. When the client’s son learned of the gift, he pressed ethics charges. The son had wanted the watch all along, but did not pressure his mother, figuring he would have it after she passed. In his defense, Dr. Time argued that the client, as an adult, had the right to make that decision. Time also contended that the client would have felt highly offended had he declined the gift.

The ethics committee did not find Time’s reasoning acceptable. It concluded that Time knew that the client had adult male children and male grandchildren, and that he should have recognized that such a personal and valuable item as a family heirloom.

PRACTICING SOLO

Therapists who work in isolation, compared to those in group practices or clinics 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 who practiced 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 total incompetence.

Perhaps if Lonely had worked in an office with other mental health professionals or joined a peer supervision group, he might have gotten sound ideas as to how to proceed with this client. They may have persuaded him to refer the client to a more suitable colleague.

The increasing popularity of working out of one’s house is understandable, from both convenience and financial standpoints. While not inherently inappropriate, we do not advise conducting therapy 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 with 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 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 just 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, ideally 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 twin bed, 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. The next case describes an actual horrifying incident.

Kevin House, L.M.H.C., held counseling sessions in the den of his home. Rose Snow, a quiet and refined woman, sought assistance in dealing with her problems, which included a cocaine-addicted daughter. Snow brought her daughter along to several sessions. One night while the House family was watching TV, several young men brandishing knives broke into the room. They terrorized the family for several hours as they gathered up valuables. It was later learned that Snow’s daughter had told her drug dealer about the “nice stuff” in the House home and provided him with a map of how to get there.

In short, a professional office setting and maintaining a solid professional identity by having easy access to colleagues can preclude serious incidents.

TOUCHING CLIENTS

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 (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. The emotionally or socially immature (e.g., children or schizophrenics) and the distressed or depressed were most frequently mentioned as the types of clients who might particularly benefit from receiving nonerotic touches (Holroyd and Brodsky, 1977). Very brief nonerotic touching on the hand, back, and shoulders are the safest areas of touch and can still convey a caring, supportive message (Wilson, 1982).

Early surveys revealed that a majority of psychologists and psychiatrists never or rarely engaged in nonerotic touching (Holroyd & Brodsky, 1977; Kardener, Fuller, & Mensh, 1973). Approximately half of the therapists responding to the Holroyd and Brodsky (1977) survey thought that nonerotic contact (such as hugging, kissing, or affectionate touching) could benefit both male and female clients under certain conditions, but only 27% reported actually engaging in touching. Subsequent surveys suggested that nonerotic 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.

In their risk-management approach to touching, Bennett, Bryant, Vandenbos, and Greenwood (1990) admonish therapists to consider first how they think the client would react. The intent of the initiator may not come through clearly to the recipient. 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.

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 – even if for only a small percentage of clients – consequences. The next case illustrates the point.

Sarah Needy felt very alone in a new, large city. On entering the fifth session with Tim Startled, M.A., she embraced and held onto him tightly and did not let go. The astonished therapist put his arms lightly around her and nervously patted her on the back. Unfortunately, Needy interpreted Startled's willingness to be held for an extended period as a nonverbal admission that their relationship had progressed beyond that of therapist and client. When, after several minutes, Mr. Startled moved away and continued with the usual mode of therapy, Needy became confused and angry. She walked out and later pressed ethics charges for “sexual misconduct.”

As a wiser strategy, Mr. Startled could have proactively shortened Needy's unwelcome surprise embrace. Even if he had to take his client's arms and set them gently aside, he could maintain a stance of caring and concern without allowing prolonged physical contact. For some clients, any form of touching under any circumstances can feel inappropriate for some clients.

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 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.

What touching never qualifies as appropriate? The general definition of erotic contact offered early on by Holroyd and Brodsky (1977, 1980) includes behavior primarily intended to arouse or satisfy sexual desires. Using this definition, such touching (excluding intercourse) was reported by 9% of male and 1% of female therapists sampled in their survey. The advantage of a definition that focuses not on the act but on the intent is that touching any part of the person is unethical if the intent were sexual gratification. An obvious drawback is that accused therapists can always deny their intent, truthful or not.

Another way to define inappropriate contact focuses on the body parts touched. For example, improper touch has been defined as coming into contact with the bare skin or through clothing of the breast of a female or the sexual organ, anus, groin, or buttocks of either sex. One advantage of such a list is that intent need not be proven. It also implicitly allows other forms of touching that should not normally raise concerns, such as shaking hands or a reassuring pat on the back. However, the list approach becomes problematic because humans can experience sensations as sexual just about everywhere on their bodies. The manner of the touch tells almost as much as the parts touched. Therefore, if a forbidden touch site is not specifically noted, one might assume that touching it is acceptable. But, is it really okay to nibble on clients' ears?

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 nonerotic touching of the opposite sex, but not same sex, clients. The authors conclude that nonerotic 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).

SEXUAL ATTRACTION TO CLIENTS

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. To have fleeting erotic feelings toward other people is part of human nature. 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). However, of the 95% of the male therapists and 76% of the female therapists who admitted to having feelings of attraction to at least one client, the majority felt guilty, anxious, or confused about it. Older female therapists were less likely to report ever feeling attraction to a client, whereas the attraction rate for younger female therapists approached that of male therapists. (as the “younger respondents” of the 1980s would today be “older respondents,” things may have since evened out.) 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. About a third believed that their clients had, on occasion, become sexually aroused while with them.

To whom do therapists become attracted? Based on the Pope et al. (1986) survey, the overwhelming characteristic was “physical attractiveness.” “Positive mental/cognitive traits” (e.g. intelligent, well educated, articulate) and “sexuality” were next, followed by “vulnerability” attributes (e.g., needy, childlike, sensitive, fragile) and “good personality.” Smaller percentages of respondents indicated attraction based on clients who fulfilled their needs (e.g. boosted the therapist's image, alleviated the therapist's loneliness or pressures at home), or became attracted because the clients seemed attracted to them, or the clients reminded them of someone else. A small number admitted feeling attraction to clients with serious psychopathology. We may debate whether some reasons seem more acceptable or at least more understandable than others do. Nevertheless, a small percentage of therapists have obviously used their attraction to meet personal, nonprofessional needs, and in doing so placed the most vulnerable clients at additional risk. For example, we know of a case where the therapist admitted to having had sexual relationships with very young, seriously troubled anorexic clients at an inpatient facility.

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 in addressing the issues of concern to you.” In the next case, the therapist got it only half right.

Lovitt Firstsight, M.A., knew after only a few minutes into the initial session with Venus Exquisite that he could not work as her therapist. He felt like a schoolboy again in her presence, had trouble focusing on what Venus was saying, and became sexually aroused. He had difficulty finding his “therapist voice” and, after 10 minutes, he gently interrupted her to say that he was not the right therapist for her. Firstsight spoke honestly with her about why and offered to help her find another therapist.

At least Mr. Firstsight understood that his initial intense feelings might not subside and had already begun to blur his judgments. He also rightly recognized that the less the client disclosed to him under the circumstances, the better. Unfortunately, in the actual incident, the therapist did not maintain a cautious stance. He married the woman within a matter of months, only to have the relationship dissolve shortly thereafter. The flattered “almost-client” and the spellbound “almost-therapist” realized that once the sparkle wore off, they had little in common and many areas of conflict.

Some might argue that Firstsight did not behave unethically because the woman had not, strictly speaking, become a “former client.” Ten minutes hardly seems enough time to have established a therapist-client relationship. Regardless, the fleeting therapeutic relationship involved sufficient emotional intensity to have warranted far more caution than Mr. Firstsight ultimately exercised.

Most instances of sexual attraction between clients and therapists do not strike with such a mighty and immediate force. More likely, a recognition that this person is pleasant to look at or intriguing in some way flickers, and soon dissipates or remains at a safe level as the therapist focuses on the demands of a working professional relationship. Of course, attraction feelings can also escalate, and that is when things can begin to unravel.

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, which constitutes poor professional practice. In addition, 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.

To conclude this section, we strongly advise that therapists discuss lingering attraction feelings towards a client with someone, preferably another therapist, an experienced and trusted colleague, or an approachable supervisor. When professional vision becomes distorted, excuses to make moves that may later be deeply regretted seem to flow all too easily. A fresh perspective will often prove helpful in clarifying the risk, neutralizing any rationalizations, and offering advice on how to proceed.

MANAGING CLIENTS’ SEXUAL ATTRACTION TO THERAPISTS

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.

What if the therapist also harbors unspoken feelings of attraction towards the client who openly discloses attraction to the therapist? In an attempt to better understand such a situation, Goodyear and Shumate (1996) simulated therapy sessions portraying a client disclosing a sexual interest in a therapist. These were then rated by groups of therapists. The portrayal of the therapist who disclosed reciprocal attraction followed by an indication that it would not be acted upon was rated as less therapeutic for the client and less skillful than a condition in which the therapist remained noncommittal.

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 helping 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. An expert witness in this case noted that borderline patients can “sneak up on you” because they can seem so ordinary at first. Such clients, according to Blatchford (2004), also often inspire empathy and a desire to rescue the client from their pathology.

ROMANCING AND CASUALLY DATING CLIENTS

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 involve the superimposition of inappropriate activities on to 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 will likely 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 the therapy relationship. The client sought and won a large damage award through a civil malpractice complaint.

SEXUALLY INTIMATE BEHAVIOR WITH CLIENTS

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 professional associations.

Therapists usually hold an advantage of power (or at least perceived power) because they become privy to intimate secrets. Clients new to therapy do not know what to expect, and they trust the therapist to act in their best interests. Consumers of mental health services also assume that their therapists have wise judgment, experience, and highly specialized skills. In addition, clients usually come into therapy with vulnerabilities, struggling with their own problems for which they have come seeking assistance. The personal power of the therapist can be so strong as to interfere significantly with clients’ capacity to make decisions that, under a different set of circumstances, would be relatively easy. Some clients may purposely seek to seduce or manipulate their therapists. Yet, as we shall see, there is no excuse for other than a professional, self-controlled response.

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 often includes 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).

Forer's (1981) classic survey conducted in California in 1968 reported that 17% of his sample of male private practice therapists admitted having had sexual relationships with clients, compared to no such sexual experiences reported by female private practice therapists or male therapists working in institutional settings. His work was so controversial that no professional journal would publish it. For a long while afterwards, 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 the professional community 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 in a struggle with their transference neuroses (Barnhouse, 1978; Schwendinger & Schwendinger, 1974). We remain hopeful that the steadily decreasing numbers indicate a continuing reduction in the sexual exploitation of clients.

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 come up 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 duty to uphold ethical, legal, and professional standards cannot be sidestepped.

When sex enters therapy, the objective helping environment vanishes. Even very early surveys of psychologists (Holroyd & Brodsky, 1977) and psychiatrists (Kardener et al., 1973) revealed that the majority of practitioners do not see any benefit to erotic contact or sexual intercourse with clients. Moreover, one of the most unsettling research findings to date is that adult survivors of familial abuse and incest seem at especially high-risk for subsequent sexual &Agresti, 1998).

The available data on harm to clients do not represent all client-therapist sexual liaisons because they consist only of instances reported to others in some way. 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).

We saw, while serving on ethics committees, 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. Complainants often expressed ambivalence, making it clear that they did not want anything bad to happen to their therapists. They just wanted them to stop hurting others.

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 taken heavy criticism (e.g., Williams, 1992). Sampling biases, 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.

Profiles of Therapists Who Have Sex with Clients

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.

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 (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 (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.

Maria Skeptic was so suspicious of her husband’s claim that he was in therapy every Thursday night that she drove to the office just to make sure his car was parked in the office lot. She arrived just in time to observe her husband pressing the therapist up against his car for a passionate full-body embrace.

Complaints by males against their female therapists remain rare but are no longer anomalies (Pope, 2001).

Lura Bird, Ph.D. attempted to desensitize sexually repressed Alvin Stifle by reciting sexual fantasies she had about him. Mr. Stifle appeared unmoved. Frustrated by his nonresponsiveness, Dr. Bird decided to ratchet up her approach and, in one session, removed her clothing and embraced Stifle as he walked in the room. They fumbled around for a while before Stifle contained himself and left, never to return. He contacted an ethics committee describing his therapist as “a scary maniac.”

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 told 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 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 infrequent scenario is the therapist who uses drugs or alcohol to enhance the treatment seduction process.

Snow White, who had been rescheduled to the last appointment of the evening by Cokie Snort, Ph.D. agreed to start staying a while later at the end of her sessions to help Snow “relax” after a long day. Snort began by serving wine, but one evening produced some cocaine. Sex and drugs soon became an integral part of an afterhours ritual.

This therapist had lost any concept of boundaries in his practice. Snort was eventually sued by several clients and lost his license to practice. Another high profile lawsuit, from which we adapted the next case, reveals an even more wicked use of drugs that was not, in our opinion, appropriately disciplined.

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. His suffered a brief license suspension, yet was allowed to resume practicing so long as he did not use this particular technique.

Though hardly an excuse, therapists who engage in sex with clients often face regrets, calamities, or deficits in their own lives. 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 to the therapist 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.

Tim Scare, Ph.D. became concerned when a client with whom he had intercourse on several occasions started calling him at home “just to say hello.” He had not predicted the increasing informality nor did he welcome it. He suggested to his client that they should terminate therapy. She asked if that meant that they would then be “just lovers.” When he responded that this relationship could not continue either, the rejected client contacted a state licensing board.

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.

Another fairly common offender profile involves inappropriate reactions to the needy or sad client who expresses implicitly or explicitly the need for physical comfort. This client can quickly become exploited by a therapist who too easily melts down boundaries.

Adam Octopus, Ph.D. had always found the delicate and petite Wilma Wilt fetching. Wilt would fall into his arms and sob every time she brought up her child who recently succumbed to cancer. Octopus began to massage and fondle her during these episodes, eventually making sexual moves to which she did not object at the time. Ms. Wilt soon realized, however, that what she needed and what she was getting were hardly one and the same. She told a subsequent therapist about Octopus' behavior, and the new therapist encouraged Wilt to press charges.

Finally, 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.

Elmer Smitten, M.S.W. was attracted to Luna Fond from the first therapy session. He recalled wanting to reach out and hold her and to take care of her. He thought about Fond constantly and anxiously anticipated the sessions with her. If Fond canceled an appointment, he felt disappointed for the rest of the day. The first social meeting occurred under conditions similar to the type that lovesick adolescents contrive. He would call to ask if she would mind changing her 10:00 A.M. appointment to 11:00 A.M. At the end of the session, he would then mention that he had not eaten all day and would casually ask Fond to join him at the little deli across the street. He later noted that he should have realized the pending danger when he found himself mentally rehearsing the invitation many times. They had lunch. There were more lunches, then dinners, and finally sexual activity. Smitten maintained that if he were free, he would have committed himself fully to this woman. Soon, the guilt about having an affair with a married man began to gnaw at Fond. Mr. Smitten began to feel pressured, and frequent spats occurred. Fond terminated both the therapy and the personal relationship, consulted another therapist, and contacted an ethics committee. Amazingly, Smitten continued writing Fond love letters, even after an ethics committee investigation had begun.

Compared with the other offender profiles, 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.

Risks to Therapists

Whereas consequences to clients as the result of engaging in sexual intimacies with their therapists can be shattering, many therapists have not fared any better. In fact, we contend that having sex with a client constitutes the most stupid thing any mental health professional could possibly do. So many perpetrators have lost their jobs, licenses, families, and reputations. Angry clients (or their significant others) become motivated to expose and sue. We know of only a few therapists who entered into relationships with their clients that lasted for more than a few months before collapsing.

Some people erroneously assume that therapists who engage in sexual intimacies with clients risk very little because sessions occur away from any witnesses. If a client complains, one can deny the accusation. Therapists can cite “fantasy,” “delusion,” or “transference” as the basis for the charges. Does this work? Sometimes it does. A substantial minority of the sexual intimacy cases result in “client-said, therapist-said” stalemates, because no substantiation exists for either party’s story. However, damaging fallout often occurs anyway because others usually know of the charges, including confidants, wives, and employers. In addition, media accounts of the allegations attract wide public notice, sometimes prior to any actual adjudication. Ethics committees usually cannot sustain a charge when the therapist denies the charges and no corroborating evidence exists. However, cases closed because of lack of evidence about a single complaint can be reopened if a subsequent charge against the same individual suggests a pattern of offending.

Most professional liability insurance policies exclude paying damages in lawsuits resulting from sexual relationships with clients. If the therapist claims innocence, the policy will cover a defense, but refuse to pay any damages if the therapist is found liable. For this reason, only rarely will a lawsuit against a therapist be cited solely for sexual misbehavior. Typically, the grounds are some form of improper treatment, making a case for incremental non-sex-based damages. For example, the family in a high profile case involving the seduction of a suicidal client settled a wrongful death charge with the psychiatrist’s insurance carrier for one million dollars.

Clients currently have increasing numbers of options for redress in addition to ethics committees, although these differ among the states. These other sources of redress include criminal law statutes, civil suits and tort actions (including malpractice), mandated reporting statutes, injunctive relief, and licensing board complaints. Other resources include the availability of expert witnesses, subsequent therapists willing to testify regarding the damage that the previous sexual activity caused, clinics specializing in treating sexual abuse by professionals, and the ethics codes of all helping professional associations used as favorite “witnesses” for the prosecution. Finally, recent scandals involving pastors, priests, and politicians have further raised the public awareness about the potential for betrayal by those to whom society has assigned its trust.

One would think that enforceable ethics codes, licensing regulations, civil law, mandatory reporting, and other legal reforms should suffice to deter even the most recalcitrant offenders. The effectiveness of these sanctions in discouraging or impeding sexual misconduct, however, remains unclear. Although the rate of sexual exploitation has appeared to decrease every decade (Pope, 2001), complaints continue, even in states where sexual misconduct with clients constitutes a criminal offense.

Some therapists fear that they may have to deal with a bogus charge by a client who misunderstood something they said or did. Some clients, as we have already seen, may have a propensity to find fault. Gutheil and Gabbard (1993) described a client who brought charges against a psychologist for conducting therapy with the top two buttons of his shirt undone.

Some clients who press bogus ethics charges may be angry, vengeful, antisocial, or severely narcissistic. It is difficult to acknowledge that anyone would unjustly risk destroying someone's professional and personal life with a false accusation of sexual contact, yet it has happened in an estimated small percentage of cases. How can therapists protect themselves against unwarranted claims of sexual impropriety and still act like a human being? The following precautions might be considered:

You may feel a sense of frustration at this point. How can one act as a caring, helping professional and also avoid any behavior that others might misconstrue or interpret as unprofessional or unethical? Slovenko (1991) suggests that one consequence of the current climate involves a “depersonalization” of therapy, with the therapist sitting defensively behind a desk and no longer coming across as a fellow human being. We believe, however, that competence, sensitivity, and a habit of regularly monitoring each client's treatment needs as well as one's own responses to each client, will help preclude problems and still allow numerous avenues of expression for caring and compassion.

POSTTERMINATION SEXUAL RELATIONSHIPS WITH THERAPY CLIENTS

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, perhaps other potential perils lurk for an indefinite period after termination of the psychotherapy relationship?

Therapists who enter into sexual and even marital relationships with former clients are 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) as the example for how the ethics code related to sex with previous clients evolved. However, we note up front that the American Association of Marriage and Family Counselors (2001) and the National Association of Social Workers (1999) have taken a very similar path. Before 1992, the ethics code of the APA was silent on the question of sex with clients after the conclusion 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. The next two cases are among those that ethics committees did accept for adjudication, even before mention of post-termination sex with clients appeared in the code.

Both clients brought ethics charges against their ex-therapists. Mr. Reciprocale charged that Mr. Anxious maneuvered him into a sexual liaison, and then abandoned him when their relationship did not meet his expectations, leaving Reciprocale considerably more troubled than ever before. Ms. Swinger argued that she had felt upset about pressure to quit therapy. Then, when Dr. Trick wanted to reverse their roles by becoming her client, the issues of self-worth that brought her into therapy in the first place reappeared more intensely than ever.

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 point in the future. However, 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. Had this code been in effect earlier, both Drs. Anxious and Trick would have been guilty of an ethics violation prima facie, without the necessity of forcing complainants to convince anyone that the termination was improper.

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 low 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 shot 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 (adopted in 2002) 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 passions for very 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 possible, however, both parties would typically go their own way and find other sources to satisfy their needs. In fact, taking human nature into account, those strictly following the provisions of the current APA ethics code are unlikely to ever consummate another kind of relationship with ex-clients, making it tantamount to a lifetime ban in most instances.

We have additional concerns 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 (Gabbard, 1994; Gabbard & Pope, 1989). If clients feel attracted to their therapists (a common occurrence) or therapists feel attracted to their clients (also very 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? The therapist's ability to remain objective with a client toward whom a strong attraction is felt, coupled with the knowledge that the two could be together eventually, is also compromised.

Although transference began as a psychoanalytic construct, even therapists using cognitive, behavioral, or other approaches to treatment often agree that the therapist becomes imbued by the client with special attributes that convey a kind of emotional authority or influence. Such feelings do not simply evaporate once clients are no longer in active therapy. Strong attachments to the therapist, not as a sexual being but as a secure base and a source of confidence even if only as a mental representation, can last indefinitely (Parish & Eagle, 2003). Thus, such dynamics may harm clients should they become, even years later, their previous therapists' lovers.

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, and her bizarre fantasies 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, 1999). 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 as always unethical (American Psychiatric Association, 2006).

SEXUAL RELATIONSHIPS WITH THE SIGNIFICANT OTHERS OF PSYCHOTHERAPY CLIENTS

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 (2002) 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 (1999) 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 there is a risk of exploitation or potential harm to the client. 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 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.

FINAL WORD

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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