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Saturday, June 19, 2010

Boundary Violations and Sexual Exploitation in Psychotherapy

In my last article, I discussed the topic of  How Psychotherapists' Self Disclosure Affects the Relationship with Clients.  As I mentioned in that post, boundary violations between psychotherapists and clients often begin on the "slippery slope" with inappropriate self-disclosure by the therapist. In this article, I will focus on when boundary violations occur where there is sexual exploitation of clients by their psychotherapists.

What Are "Boundaries" in Psychotherapy?
The term "boundaries" in psychotherapy is a metaphorical term that refers to the definition and professional structure of the psychotherapy relationship. It defines the psychotherapeutic relationship as being different from a personal relationship or a friendship. The boundaries of the psychotherapeutic relationship include, but are not limited to, the time that the psychotherapist and client spend together in a professional setting, the fee arrangement, the psychotherapist's self-disclosure, the type and frequency of between-session phone calls, the prohibitions with regard to physical touch, and other related issues.

The purpose of maintaining appropriate professional boundaries in psychotherapy is, first and foremost, to protect the client from inappropriate behavior by the therapist which can be psychologically harmful. Secondly, maintaining appropriate professional boundaries also protects the therapist with regard to accusations of unethical and illegal behavior which could result in malpractice lawsuits, professional sanctions and, in the worst cases, revocation of professional licenses and/or arrests.

As I mentioned in my prior article, it is always the therapist's responsibility to maintain appropriate professional boundaries in treatment, regardless of whatever the client might do or the type of therapy.

How Often Do Boundary Violations Occur in Psychotherapeutic Relationships?
It is difficult to come up with accurate numbers because many boundary violations, especially sexual exploitation, are not reported. Many clients feel ashamed and blame themselves for the boundary violations.

Most boundary violations occur with male therapists who are older, more established, and also well trained. This is not to say that boundary violations never occur with female psychotherapists. However, based on available data, it seems to be less prevalent. In the US, it is estimated that nearly half of all malpractice suits are related to psychotherapists' sexual exploitation of clients and most of these suits are against psychiatrists.

The good news is that these type of boundary violations seem to have decreased somewhat over the years, possibly due to stiffer penalties, professional sanctions, refusal of malpractice insurance companies to provide insurance to therapists who have transgressed with clients, and better training. While this is good news, even one boundary violation between a therapist and a client is one too many.

Non-Sexual Boundary Violations that Can Lead Down the "Slippery Slope" to Sexual Exploitation:

Excessive self-disclosure: See prior blog post

Dual relationships:
Most mental health professionals' codes of ethics prohibit dual relationships because it is recognized that this is usually harmful for the client. The psychotherapeutic relationship should be the only relationship between therapist and client. Even when the dual relationship is not sexual, it violates the professional boundary between therapist and client. For instance, if a therapist has a client who happens to be stock broker, the therapist should not ask the client for stock market advice and, it goes without saying, that the therapist shouldn't ask the client to handle his or her money for stock market transactions. Once the professional boundaries have been breached, the treatment is placed at risk for even greater boundary violations.

Too Many Unnecessary Phone Calls Between Sessions:
While most therapists recognize the necessity of some phone calls between sessions to reschedule appointments or to help clients who are in a particular crisis, most therapists also know that too many unnecessary phone calls between sessions should be explored during in-person sessions with the client. Needless to say, I'm not talking about clients who are home bound or sick and have phone sessions with their therapists. Rather, I'm referring to clients who might not understand the professional treatment frame and who want to treat their therapist like a friend. As in all of these examples, it's up to the therapist to address the issue and set appropriate limits.

Therapist's Failure to Maintain the Treatment Frame:
While it is understood that there are times when certain clients might need extra time in a therapy session due to a crisis or they might need a temporary fee agreement due to financial necessity, when the therapist fails to maintain the treatment frame on a frequent basis with a particular client, this is usually indicative of the therapist's boundary violation in the treatment, which might be conscious or unconscious on the therapist's part.

I often work with clients on a sliding scale basis, when I have available open slots to do so. I have also extended my services to longstanding clients on a pro bono basis for a limited amount of time when they've lost their jobs. However, in all these instances, I've carefully considered the particular circumstances of the client and the nature of our professional relationship to make sure that I'm not enacting a boundary violation by giving "special treatment" to certain clients. If it's clear that a client can afford to pay the full fee, I see no reason to provide a sliding scale fee and I would see this as an unprofessional enactment with the client.

Touching or Frequent Hugs:
As a matter of course, I do not touch my clients. I am very aware that, for many clients, touching has particular inappropriate implications, especially for clients who were sexually abused, and even more so in cases of incest. The therapeutic relationship can often take on the appearance and feeling of a parent-child relationship. It's very important for the client to feel that he or she can trust the therapist. No matter how non-hierarchical or egalitarian a therapist might try to be, the client-therapist relationship is, by definition, an unequal relationship where the therapist has more power than the client--even in therapy relationships where the client is a therapist.

Like most examples, there are some limited exceptions. At the conclusion of a long-term therapy relationship, many clients spontaneously hug their therapists. This is usually an expression of their gratitude and caring for the therapist. While I don't initiate these hugs, I would not hurt a client's feelings by trying to ward off a hug under these circumstances.

The problems with touching and frequent hugs is that they can easily develop into more inappropriate seductive touching of an intimate or sexual nature, once again, crossing the therapeutic boundaries of treatment.

The above list is certainly not exhaustive, but it represents some of the more common non-sexual boundary violations that often lead to sexual boundary violations.

To illustrate the points that I have made above, the following fictionalized account is an example of a sexual boundary violation between a psychotherapist and his client:

Betty began attending psychotherapy sessions with Dr. Smith after she lost the third job in a row for getting sexually involved with her supervisor. Dr. Smith was highly recommended to her by a friend as a psychiatrist who was both a psychotherapist and psychopharmacologist.

Betty, who was in her mid-20s, had never been in therapy before, so she didn't know what to expect. Dr. Smith talked to her about what would be expected of her with regard to the treatment frame (i.e., coming to sessions regularly and on time, paying fees in a timely manner, the length of treatment sessions, and other related issues). He also talked to her about his professional obligations with her.

After several sessions, Betty began to have erotic feelings for Dr. Smith, which is not unusual in psychotherapy. This is often part of clients' transferential feelings for their therapist. Most of the time, these tranferential feelings have little to do with the therapist and more to do with the client's underlying, unconscious issues.

Betty tended to be seductive in her relationships with most people, including her professors, work supervisors and other authority figures in her life. At that point in the therapy, she was unaware of how she attempted to sexualize her relationships. So, it was not surprising when she began to come to therapy with revealing, low-cut blouses and short skirts.

When Dr. Smith addressed and explored this seductive behavior in therapy, Betty wasn't sure how to respond to this. In the past, due to her seductive nature and the fact that she was extremely attractive, most people responded to her seduction by engaging in sex with her. Although she usually felt powerful at first, these sexual encounters ended up being emotional disasters for her. It was the cause of many problems for her in college as well as in her work relationships with supervisors.

As the therapy progressed, it came to light that Betty had been sexually abused by her maternal uncle from the time that she was 10 until she was in her late teens. According to Betty, it began with inappropriate touching and progressed to sexual intercourse when she was in her teens. As an only child of a single, alcoholic mother, Betty craved attention and she was easy prey for her uncle, who lived with Betty and her mother.

Although she felt that her uncle's sexual attention was wrong, she was vulnerable to him because she was an emotionally neglected child. She also told herself that she must be "special" for her uncle to want to spend time with her in this way, so she never told anyone about it. The only reason that the incest stopped was because as Betty got older, her uncle, who turned out to be a pedophile with other children too, no longer found her sexually exciting. As is often the case with pedophiles, he needed to enact his sexual transgressions with children so he stopped approaching Betty in a sexual manner. And, even though she attempted to seduce him back into their incestuous relationship to get his attention, he "abandoned" her, presumably, for a younger child.

Having been sexually violated at such a young age, Betty learned to sexualize most of her relationships with men when she wanted attention. As a result, she continued to enact the sexual transgressions as an adult but, instead of being the one who was seduced, she took on the role of the sexual aggressor, albeit with adults and not children, to continue to get attention and gratify her emotional needs.

When Dr. Smith did not respond to her sexually provocative clothing in session, she began calling him between sessions "to chat." Dr. Smith responded to her calls by telling her that, unless she had an urgent matter or she needed to change an appointment time, she should wait for their next therapy session to talk to him. Undeterred, Betty began leaving frequent voicemail messages for Dr. Smith late at night, letting him know that she was thinking of him and couldn't wait to see him again.

At that point, Dr. Smith consulted with his former, more experienced clinical supervisor to get clinical advice on how to handle this client. His supervisor knew Dr. Smith well and knew him to be an ethical psychiatrist. However, he also knew that Dr. Smith was going through a tumultuous divorce, he was lonely, and he could be vulnerable to Betty's seduction. He reminded Dr. Smith of his professional and ethical obligations under their professional code of conduct. Then, he asked Dr. Smith about his countertransferential feelings for Betty. Dr. Smith admitted to his supervisor that he found Betty very attractive and sexually tantalizing, as most men probably would. However, he told his supervisor that he didn't want to cross the professional boundary with this client.

Dr. Smith's supervisor told him that if he could work out this issue with Betty, it could be an important breakthrough in her treatment and she could deal with the original incest rather than continuing to engage in sexual enactments. However, he also told him that if he thought that he might violate the therapist-client professional boundaries with Betty, he should refer her to another therapist, preferably a woman. Dr. Smith's supervisor knew that Dr. Smith had a narcissistic streak to his personality, and he assured him that referring the client to another therapist would not be considered a professional failure. Rather, it would be a wise move to protect the client and to protect himself from crossing the professional boundary, especially at a time when Dr. Smith was in so much emotional turmoil himself and he was feeling lonely.

Dr. Smith agreed to consider the wise advice of his clinical supervisor. He knew that he actually felt more tempted than he admitted to his supervisor to breach the professional boundaries of the relationship, but he also knew that he would perceive himself as a failure in this case if he referred Betty to a colleague, and he was determined to work through the transferential and countertransferential issues in this case.

As treatment continued, Betty continued to be seductive with Dr. Smith. The more he attempted to maintain the treatment frame, the more determined she appeared to be to violate it. He attempted to talk to Betty about her uncle's sexual abuse, but she would find ways to bring the conversation back to her erotic feelings for Dr. Smith.

During that same time, Dr. Smith was feeling increasing emotional pressure from his divorce proceedings, which became nasty and heated. He was receiving email messages from his wife telling him that she thought he was "less than a man" and he was "spineless." His lawyer encouraged him to settle on his wife's demands and put the whole thing behind him, but Dr. Smith didn't want to give up the battle.

This resulted in many sleepless nights, poor appetite, and the beginning of his isolation from friends, family and colleagues. Within a few months, he felt like an emotional wreck. He knew that he should probably take a short sabbatical from his private practice, but he didn't want to admit that he needed a rest, so he continued to see clients, including Betty.

At the end of a particularly difficult week where he had gotten very little sleep and he was emotionally and physically exhausted, Dr. Smith saw Betty for her usual weekly session. As usual, she was wearing a sexually provocative outfit and she talked to him about her erotic feelings for him. Whereas in the past, she limited herself to telling him that she was "turned on" by him and would like to have sex with him, this time, she was more sexually explicit. Dr. Smith felt himself getting sexually aroused, but he maintained his professional demeanor. However, by the end of the session, when Dr. Smith and Betty stood up for her to leave, she locked the door and began kissing him on the mouth. Emotionally depleted by his personal problems, Dr. Smith gave in to Betty's sexual advances during that session.

By the time Betty left, Dr. Smith began to panic and he called his clinical supervisor for an emergency session. His clinical supervisor met with Dr. Smith, reprimanded him for violating the client-therapist boundary, and told him that he needed to apologize to Betty and tell her that he could no longer see her and he would refer her to a female therapist. He told him take a sabbatical from his private practice, seek his own personal therapy to deal with this transgression and with his overwhelming personal problems, and consult with a malpractice attorney in case Betty took action against him.

He also told Dr. Smith that he was obligated to report this sexual exploitation to their ethics board who would investigate the case. In addition, he told Dr. Smith that if he did not agree to follow all of these recommendations, he would also report that to their professional ethics board immediately and advocate for his license to be suspended.

Dr. Smith felt a lot of remorse for crossing the client-therapist boundary. He knew that, regardless of his personal problems and regardless of how seductive Betty was, as a mental health professional, he was responsible for maintaining the professional boundary between them.
When he apologized to Betty and told her that he could not see her again, she was crushed. This boundary violation and termination of treatment represented a repetition of her earlier problems with her uncle. Dr. Smith referred Betty to a seasoned female colleague, admitting that he had violated the therapeutic relationship and expressing his remorse.

Over time, Betty was able to work through the sexual exploitation in her therapeutic relationship with Dr. Smith as well as the original incest with her uncle. It was not easy or quick, and Betty also tested the professional boundaries with the new therapist. However, ultimately, her therapy was a success.

Dr. Smith took a sabbatical from his private practice. He entered into his own personal therapy to deal with the boundary violation as well as his divorce and loneliness. He also consulted with a malpractice attorney. After long and careful consideration, he decided to change his career focus from his psychotherapy private practice to psychotherapy research.

As this fictionalized scenario demonstrates, even when the psychotherapist is determined to maintain professional boundaries and seeks out clinical supervision to deal with the erotic transference and countertransference, there are so many personal and professional factors that can jeopardize a treatment.

Psychotherapists need to be emotionally attuned to their own professional and personal vulnerabilities before they slide down the "slippery slope" of crossing boundaries with a client.

Although the fictionalized account that I presented was between a heterosexual therapist and client, these boundary violations also occur among gay and lesbian therapists and clients.

In most cases, sexual exploitation in psychotherapy doesn't occur immediately. It usually follows after minor boundary violations turn into larger violations, culminating in the most egregious violation of sexual exploitation.

Also, in many cases where there is sexual exploitation in therapy, the psychotherapist, and not the client, is the aggressor. So, it goes both ways.

I intentionally presented a fictionalized account where the client is seductive and has a history of seducing authority figures due to childhood incest because this is a common scenario. Also, I wanted to demonstrate that even if cases where clients are extremely seductive, the therapist is the one who is still accountable for maintainng profesional boundaries.

If you are a psychotherapist who has crossed professional boundaries with your client, it is very important that you seek clinical supervision, no matter how long youve been practicing or how experienced you are. In most cases, therapists who have violated clients' boundaries should also seek their own personal therapy to work through these issues and do some soul searching as to whether they are in the right profession.

If you are a client who has been sexually exploited in therapy, don't suffer in shame alone. Although it might be hard for you to trust another therapist again, first, seek out a psychotherapy recommendation from your doctor or a trusted friend to work through this abuse.

Second, if you should decide to take legal action against this therapist for what he or she did to you and because you suspect that the therapist might be perpetrating this inappropriate behavior with other clients, seek out the advice of the ethnics board for the professional organization with whom the therapist is affiliated. So, it would be the American Psychiatric Association for psychiatrists, the American Psychological Assocation for psychologists, and the National Association of Social Workers for clinical social workers. You can also seek out the advice of the ethnics department for the State licensing board, who provides licensure for that particular profession. You can find this information online for your particular State.

I am a licensed NYC psychotherapist, hypnotherapist, EMDR and Somatic Experiencing therapist.  I work with individual adults and couples.

To find out more about me, visit my website: Josephine Ferraro, LCSW - NYC Psychotherapist

To set up a consultation, call me at (212) 726-1006.

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