Reduce sexual boundary crossings

Sexual contact between clinicians and patients is a strikingly common occurrence, and two reviews indicate the extent of the issue. First, a 2007 literature review determined that between 22 and 26% of patients reported to their new practitioner that they had been sexually involved with a previous clinician, and between 38 and 52% of health professionals reported knowing of colleagues who had been sexually involved with patients.1 A second review determined that between 7 and 12% of professionals in the mental health field engage in erotic contact with clients.2 These figures are surely underestimates, since prevalence studies rely on anonymous self-reporting of offending clinicians, clients themselves, other staff members who know of an incident, or the accounts of clinicians dealing with a new client who had experienced past sexual boundary violations.

Why do staff members, many of whom seem to be otherwise outstanding and often invaluable employees, risk catastrophic consequences via engagement in sexual boundary crossings? Potential repercussions include loss of licensure or certification, expulsion from professional associations, loss of employment, loss of colleagues, the ending of marriages, legal action, financial repercussions, and, in some states, probation or imprisonment. While it would be comforting to conclude that these professionals are characterologically disturbed, the research is very clear and finds a far more worrisome conclusion: Risk is based on an ever-changing conflux of clinician characteristics, client characteristics, the nature of the therapeutic relationship in general, an agency’s milieu, and supervisory relations. A clinician who is at low risk today might be at much higher risk several months from now. Still, staff members of all disciplines minimize or outright deny this risk.

Treatment organizations also are in denial, as evident from continued use of preventative practices that are not working as they are commonly implemented. These include trainings, statements about this behavior in workplace rules and regulations, clinical supervision, and an overriding belief that knowledge of the ethical requirements of one’s discipline will serve as a deterrent. In short, the methods in use today will not significantly affect the prevalence of erotic boundary crossings between a staff member and a patient.

Understanding the process

The field of sex offender (SO) treatment is indebted to the behavioral health field; many of the latter’s models were the original building blocks of SO treatment (such as the concept of relapse prevention planning). However, as the SO field has evolved, the behavioral health field has been loath to consider sex offender treatment theories, models and practices, many of which help us understand professional boundary crossings.

Some principles used in SO treatment that are applicable to the behavioral health field in general include:

• Typologies. The SO field continues to develop typologies for offenders to guide assessment of risk and clinical intervention, and efforts have been undertaken to elucidate subtypes of clinicians who engage in erotic boundary crossings. In an early example, Schoener and Gonsiorek identified six subtypes of transgressing professionals, ranging from the uninformed and naïve type to those with sociopathic or narcissistic characteristics.3 At present, a general typology accepted in the field contrasts one-time clinical boundary crossers, who often seek help and are genuinely remorseful, with repeat (also called predatory) clinical transgressors who have engaged in the behavior repeatedly, have little remorse, and have little likelihood of rehabilitation. Finally, it is well known that the overwhelming majority of such clinicians are men, and Celenza determined that the most common transgressor is a middle-aged male therapist in private practice who engages in sexual contact with one female patient.2

• Beliefs. Sex offenders have underlying belief systems shaped by their upbringing that influence their behavior, particularly beliefs about gender, power and sex. Integral to SO treatment is the recognition of such beliefs and an acknowledgement of their impact on sexual behaviors. Similarly, clinicians begin their work with behavioral health agencies possessing many explicit and implicit beliefs about these same topics in addition to others that have immediate clinical salience. Examples include beliefs about physical touch, personal disclosure, flirtation during sessions, and, even more controversial, use of fantasies of a client for personal sexual gratification.

• The offense process. One of the precepts of SO treatment is that a sex offense does not “just happen.” There is a series of intervening steps leading up to an offense, and interventions can be specifically targeted for each step. There have been attempts to formulate a similar process model for professional boundary violations. Martin and colleagues interviewed professionals who had become sexually attracted to clients, which led to the formation of a process model applicable to clinicians.4 Their five-step model entails acknowledging sexual attraction to a client and ultimately progressing to the formulation of methods to use the situation therapeutically for the client’s benefit.

• Thinking errors or cognitive distortions. SO treatment identifies recurrent cognitive distortion that facilitates a sex offense. While there is indeed overlap between SO and professional boundary crossings, it would be helpful to identify distortions prevalent in the latter population. This work is in its infancy, but a study by McNulty and colleagues offers insight. Through interviews with professionals who had engaged in erotic boundary violations, the authors discerned the theme of neutralization of a client’s “patientness.” Clinicians did not begin a relationship until they believed a patient’s psychological issues had been resolved. At this point power balances were ostensibly dissolved, professional boundaries could be more lax, and a conventional relationship was seen as possible. In short, a reduction in mental health symptoms was a pre-condition for boundary crossings.5

Prevention and intervention

From an organizational perspective, the unearthing of sexual contact between a staff member and a client leads not only to lawsuits, police and governmental investigations, bad press, and the dismissal of once-valued staff members, but also to institutional trauma. Pervasive denial, helplessness, anger and guilt form a toxic environment that infiltrates the lives of all employees in a treatment organization.6

The statistics on professional erotic boundary crossings make it clear that preventative practices as they are currently implemented do not work. What, then, can be done? The first step is to incorporate the research of the SO field into existing protocols:

• Screening. SO treatment has formulated a number of risk assessments, but measurement tools for risk of professional erotic boundary crossings are almost non-existent. As one example, Celenza introduced the Boundary Violations Vulnerability Index as a tool for practitioners of all theoretical orientations to use for self-assessment and self-monitoring.2 As a screening tool for new hires, this would be unwieldy, but as a tool for use during clinical supervision it is well worth considering.

• Comprehensive training. At present, trainings typically consist of reminders not to engage in boundary crossings with patients and a description of the consequences that could ensue. Sadly, for many professionals, even this is not occurring. Pope and colleagues surveyed 575 psychotherapists and found that 87% (95% of men, 76% of women) had been sexually attracted to their clients, at least on occasion. They also found that about half of the respondents did not receive any guidance or training concerning this issue.7 Comprehensive trainings need to address uncomfortable topics such as sexual arousal, fantasies and personal beliefs about gender, sex and power. Those leading the training will need to be both experienced and comfortable with the topic, so as not to risk humiliating and shaming participants or coming across as prurient or even pornographic.8 Organizations also might want to consider offering supplemental male-specific trainings based on men's heightened risk.

• Enhanced supervision. There is a consensus that decreasing the prevalence of erotic boundary crossings requires supervision by those knowledgeable and comfortable with the issue. However, this is a rarity. Referring again to the Pope study, only 9% of clinicians reported that their training or supervision was adequate.7 Supervisors are uncomfortable with the topic of erotic boundary crossings, do not have enough information to address the topic, or are fearful that bringing up the topic could be misinterpreted by a supervisee as a sexual overture. Supervision on this topic is simply not occurring, and supervisors will need to be trained to address it.

Recommendations

Therapy in itself is an intimate encounter. Two people talking face to face in a setting in which personal and possibly erotic or stimulating disclosure is a norm can be an overwhelming and confusing experience for even the most seasoned clinician. There is therefore an urgent need to move from the current model of cautioning staff against this behavior and then hoping for the best to one that:

• Acknowledges the commonality of sexual attraction to clients.

• Assists all staff members in acknowledging that they are at risk for erotic boundary crossings, and that this risk level changes.

• Offers self-assessment for vulnerability to erotic boundary crossings.

• Offers comprehensive experiential training, including topics such as arousal, fantasy and beliefs. Also, training teaches that sexual boundary crossing is a process, and staff members have multiple junctures in which to seek assistance voluntarily before escalating to activities that can lead to career-jeopardizing consequences.

• Offers supervision capable of discussing arousal and attraction.

• Develops a policy for handling disclosures of attraction to clients that is non-punitive. The earlier a staff member seeks help, the less likely this is to lead to an outright irreparable ethical and possible criminal offense.

Michael Shelton is a former board member for NALGAP, The Association of Lesbian, Gay, Bisexual, Transgender Addiction Professionals and Their Allies, and is one of the country's foremost experts on sex and sexuality in treatment. His written works include the newly published Fundamentals of LGBT Substance Use Disorders (Harrington Park Press).

References

1. Halter M, Brown H, Stone J. Sexual Boundary Violations by Health Professionals: An Overview of the Published Empirical Literature. United Kingdom: Council for Healthcare Regulatory Excellence; 2007.

2. Celenza A. Sexual Boundary Violations. Lanham, Md.: Jason Aronson; 2007.

3. Schoener GR, Gonsiorek J. Assessment and development of rehabilitation plans for counselors who have sexually exploited their clients. J Couns Devel 1988;67:227-32.

4. Martin C, Godfrey M, Meekums B, et al. Managing boundaries under pressure: A qualitative study of therapists' experiences of sexual attraction in therapy. Couns Psychother Res 2011;11:248-56.

5. McNulty N, Ogden J, Warren F. Neutralizing the patient: Therapists' accounts of sexual boundary violations. Clin Psychol Psychother 2013;20:189-98.

6. Honig RG, Barron JW. Restoring institutional integrity in the wake of sexual boundary violations: A case study. J Am Psychoanalytic Assoc 2013;61:897-924.

7. Pope KS, Keith-Spiegel P, Tabachnick BG. Sexual attraction to clients: The human therapist and the (sometimes) inhuman training system. Train Educ Prof Psychol 2006;S:96-111.

8. Murray KW, Sommers-Flanagan J. Addressing sexual attraction in supervision. In Luca M (ed.). Sexual Attraction in Therapy: Clinical Perspectives on Moving Beyond the Taboo. West Sussex, United Kingdom: John Wiley & Sons; 2014.