SPECIAL SERIES: Treatment centers have capacity to lessen chance of sexual misconduct

Leaders in the credentialing of addiction professionals insist that treatment facilities can wield influence in stemming inappropriate sexual behavior by staff—incidents that are under-reported and damaging to organizations' reputation and bottom line.

“If [clinical] supervision were more centered around the ethics of those counselors, we would see a decrease in the number of ethics complaints,” says Mary Jo Mather, executive director of the International Certification & Reciprocity Consortium (IC&RC), representing credentialing boards. “I can’t tell you the number of times I get a call from a counselor who’s asking me about an ethics question, and they never thought to ask their supervisor. There’s something wrong with that.”

Supervisors need to be aware of issues surrounding inappropriate actions toward patients, and not help treatment program administrators sweep them under the rug, says Patterson. One problem, she says, is that schools no longer are teaching about transference and countertransference, the phenomena in which a patient views the therapist as representing someone important in his/her life (such as a mother or husband) and the therapist in turn projects some feelings onto the patient.

Many addiction counselors come out of school thinking they’re supposed to be a robot, says Frances Patterson, a member of the ethics committee for NAADAC, The Association for Addiction Professionals. “They think they’re not supposed to feel, they’re not supposed to like a client or dislike a client,” Patterson says. “Then when they have these feelings, they think there’s something wrong with them.”

That’s a key part of supervision, which has to be ongoing, says Patterson, adding, “You never outgrow supervision—that’s what keeps us out of trouble.” It’s also helpful to remember that if you’re doing something you don’t want to talk to someone about, there probably is something wrong, she says.

Kathryn Benson, chair of the National Certification Commission for Addiction Professionals, which is run by NAADAC, frequently talks on the phone to counselors who are confused. “It’s not their fault if they’re not getting good guidance from their agencies,” Benson says. “They’re afraid of retaliation. I’m not going to let them hang alone out there.”

On the other hand, it also is hard to blame supervisors, because most of the time they are “doing the best they can with what they are working with,” says Benson. “This isn’t about pointing fingers—it’s about coming up with a solution.”

Sometimes the counselor is so afraid of the situation that he/she doesn’t tell anyone, including the supervisor. But this fear proves destructive, says Benson. “I tell people they will get trapped in their own fear, because if you find yourself attracted to a client, you’ll get trapped into thinking that there’s something wrong with you, and you’re defective as a counselor,” she says. “You’re having a human feeling.”

The counselor’s job is to convey this to the supervisor, and the supervisor’s job is to understand that this is human nature, and that the supervisor will help the counselor manage this.

“This is about real life,” says Benson. “You cannot prevent everything.” Even with the best policies and the best training, treatment programs still may not be able to prevent sexual misconduct. But where the true liability lies is in how the treatment program responds to a situation once aware of it.

Benson stresses that the absolutely wrong move to make when an incident of sexual misconduct occurs is to transfer the patient immediately to another counselor. “That’s the mark of a poorly trained supervisor and clinician, who believes that the first response is to transfer,” she says. “That’s harmful to the counselor and to the client.” Many people come to treatment with abandonment issues, and if the first time they show up they get rejected—which is how they will interpret a transfer to another counselor—they will feel that they really must be worthless if even the therapist doesn’t want to talk to them, Benson explains.

Patient blaming

Benson says patients don’t seduce counselors. Rather, the patient comes into a program and is at the level of coping that he/she has in life at the time. “It’s not at all uncommon, particularly for females, to use their bodies,” she says. “They use sex as a way of controlling and minimizing further damage to themselves.” It’s a convoluted sense of survival, but by being in control of sex, these women believe they can reduce their chances of being harmed.

Counselors are trained in how human beings developed coping skills to help them survive, says Benson. “The burden is always on the clinician, on the staff person, to manage themselves,” she says. “We’re the professionals.”

Patterson is outraged when she hears counselors claim to have been seduced by patients. “The patient is acting like a patient, using the coping skills she has,” says Patterson. “The only way she knows how to interact is sexually.”

Because of the disease patients arrive with, and the past trauma they may have experienced, it may take them months or more to report sexual misconduct, says IC&RC's Mather. “Maybe a year later they’re back in treatment someplace else, and they realize this wasn’t supposed to happen,” she says.

Dual relationships

The concept of sexual misconduct has been broadened to include dual relationships, which are banned by ethics codes. A dual relationship is one that is outside of the clinical care the counselor is providing. On one end of the spectrum is running into a patient or former patient at a 12-Step meeting and interacting with them with a “social feel” to the relationship, including an activity such as going out with a group for coffee. On the other end of the spectrum is full physical intimacy. The potential harm to the client varies, but it exists in all dual relationships.

Sean Conaboy, a risk management consultant with NSM Insurance Group in Philadelphia, recalls the slippery slope of relationships he witnessed in treatment programs. “When I was managing facilities and doing clinical supervision, I would see the relationships that would start to occur, and blossom into something that was inappropriate,” Conaboy says. “We had to do a lot of training, a lot of policies and procedures. This is a danger sign, but these are human beings, and it happens. You have to deal with it.”

IC&RC recently changed its code of ethics to ban not only exploitation of clients, but also dual relationships. “Sometimes it isn’t physical, but it has crossed over from the professional relationship,” says Mather. “Maybe they’re texting at night, meeting for coffee, not doing anything sexual. It’s still a dual relationship, and not allowed.”

Role of non-clinical staff

While administrative staff are less likely to have dual relationship issues, they do get to make the big decisions. They’re the people in power, and as Patterson said, “They look at lawsuits and the bottom line.”

That’s why consultants who work with treatment programs on ethics training frequently request to meet with non-clinical staff as well as clinicians. Treatment centers, says Benson, need to understand that the costs of letting the counselor simply go work at another program, with nothing ever reported, are too high.

When Benson works with a facility that is going through a sexual misconduct situation, she tells administrators that they need to terminate the employee, report the person to the appropriate authority, get the patient placed in another treatment program, and pay for that treatment. “They do not like hearing this,” she says.

Importance of investigating

While investigating claims is onerous and expensive, it’s something that treatment programs need to do, says Conaboy. “Firing the counselor and hoping they don’t get sued won’t make the problem go away,” he says. Conaboy stressed that no attorney will sue only the counselor—the employing organization will get sued as well.

All cases end up being settled out of court, because treatment programs don’t want the publicity of a trial, says Conaboy. “Attorneys [for patients] make their money on the settlements, and on the billable hours,” he says.

An organization must be acutely aware of the dangers of wrongful termination, says Conaboy. “We’ve all worked and dealt with transference,” he says. “Patients lie, they fabricate, they’re delusional, they’re trying to get back at you. So don’t rush to judgment.” There must be due process, in which allegations are thoroughly investigated.

Sexual misconduct presents a “very challenging set of dynamics” for a treatment organization, says Conaboy. “And no matter how well managed you are, these things still happen, because this is human behavior.” Some of the most prestigious programs have experienced these situations, he says.

All hospitals have general, professional, and sexual misconduct/abuse and molestation insurance coverage, and behavioral health providers should as well, says Conaboy. “Different carriers handle the premiums differently,” he says. In many cases, the sexual misconduct coverage is bundled into general and professional liability coverage.

A preventive culture

“Ethical violations don’t happen in a vacuum,” says Sandy Wummer, corporate director of performance, standards and research at Pennsylvania-based Caron Treatment Centers. “We try from the beginning to create a culture of ongoing training and supervision around ethical issues.”

Caron focuses on preventing ethical violations, says Wummer. A key component involves having a treatment team, not a single individual, treating each patient, she says. “When there are multiple staff members, this eliminates some of the boundary issues, the transference and countertransference,” Wummer says.

She adds, “Ethical issues always arise, in any kind of medical treatment. It’s how you respond that matters.” Caron also educates patients and their families about ethical and appropriate behavior “on our part and on their part,” she says.

What if the sexual relationship is between patients? “This is a clinical issue, a treatment team issue,” says Wummer. “There are patients whose histories may lend themselves to that behavior—patients come here with a lot of issues.”

If a patient reports sexual misconduct, Caron has processes in place to investigate. “It’s a patient advocate process,” says Wummer. “We take every allegation seriously. In the rare case that we have an allegation of an inappropriate relation between a staff member and a patient, we would explain to the counselor first that there is an allegation.” In some cases, the counselor would have to stay home until the investigation is concluded.

“If we find an allegation to be accurate, we would take appropriate steps through the HR process and the licensing boards,” says Wummer. “That is not a choice—that is a regulation.”

It’s important to use an allegation, whether it’s true or not, as an opportunity for training, supervision and learning, she says. Doing nothing in response to an allegation sets up an organization for liability in many areas, says Wummer.

“It will cause repeat behavior,” she says.

Alison Knopf is a freelance writer based in New York.

One patient's ordeal

Pamela Banker, who lives in Geneseo, N.Y., was arrested for drunk driving and had been sent to court-ordered treatment in 1999. The counselor who supervised her told her that if she didn’t submit to his sexual advances, she would be sent to prison for 14 years.

When Banker did report the abuse (which she said went on for seven years) to her probation officer, the officer told the counselor. He retaliated by forcing her to plead guilty to drunk driving in the treatment court where he served as coordinator, so that she would stay under his jurisdiction.

Ultimately Banker was sent to prison for three years, for relapsing to alcohol use, which was triggered by the sexual abuse. The counselor eventually was allowed to resign, citing health reasons.

Banker’s story was not reported until she filed a lawsuit in 2009, citing the abuse. The employer was the state because she had been in a state-run treatment program. The state refused to pay any award, saying that what the counselor did occurred outside of his purview as an employee.

The state Office of Alcoholism and Substance Abuse Services (OASAS) did confirm to Addiction Professional that its review of the situation concluded that the counselor had violated applicable ethical standards. OASAS adds that he is no longer credentialed by the state agency.

The patient's lawsuit was dropped, and Banker, who lives on $750 a month in disability, says she owes her lawyer more than $6,000. In August, a reporter with the Democrat & Chronicle newspaper met with her, and published her story on Aug. 29. Addiction Professional contacted Banker in early September, and she said she wants her story to be told. To access the Democrat & Chronicle article, click here.