Assessment & Rehabilitation of Psychotherapists Who Violate Boundaries With Clients

by Gary Richard Schoener

Gary Schoener is a licensed psychologist and Executive Director of the Walk-In Counseling Center in Minneapolis, MN.  He is the senior author of "Psychotherapists' Sexual Involvement with Clients: Intervention and Prevention",  co-author of "Assisting Impaired Psychologists", and has written many articles on this topic.  Schoener has consulted in more than 3000 cases of sexual misconduct by professionals and was a member of the Task Force on Sexual Impropriety of the American Psychological Association and its Advisory Committee on the Impaired Psychologist.  The Walk-In Counseling Center was the recipient of the 1977 Gold Achievement Award in Hospital and Community Psychiatry from the American Psychiatric Association.

This article has been reproduced with permission from the Walk-In Counseling Center.  Copyright © 1998 WICC.

Preface

Presented to the Norwegian Psychological Association in Oslo, Norway - 3 & 4 September 1997.  This is a revised version of a paper entitled "Assessment, Treatment, & Supervision of Professionals Who Engaged in Boundary Violations" which was presented at the 1st Australian & New Zealand Conference on Sexual Exploitation by Health Professionals, Psychotherapists, & Clergy, held 12 April 1996 at the University of Sydney, Sydney, Australia.  Edited by AdvocateWeb, with permission from the author.

Introduction

Prior to the last decade sexual misconduct and related boundary violations by counselors and other professionals was often treated with an attitude of tolerance. Offending professionals received mild discipline, returned to practice while receiving some sort of psychotherapy or counseling and possibly supervision of their work. Typically no formal assessment was done to determine rehabilitation potential. A number of psychotherapists and counselors were apparently willing to undertake the treatment of such cases with only limited knowledge of the original offenses and without a clear plan for how a repeat of the behavior was going to be prevented. The focus of such therapies was whatever the offending professional wanted to discuss. Often the professional misconduct received little or no attention. The etiology of the unprofessional conduct might not even be identified. Professionals often were deemed "cured" after a course of therapy which largely addressed distress and/or depression which was secondary to having faced discipline.

Even when a more targeted approach was taken to the planning of a rehabilitation effort, a subsequent employer, board of licensure or registration, or college might undermine the plan. It is quite common, even today, for example, for a practitioner to be required to obtain a clinical internship or a very formal type of supervision but be unable to do so. The practitioner then appeals to the licensing or regulatory authority which relents and allows a lesser level of training or supervision. For example, in a case described by Bates & Brodsky (1989, p. 80):

But the board did not hold to the original five mandates. The results of the psychological evaluation ordered in the first mandate may not have offered great promise for rehabilitation. The second mandate had to be altered: Dr. X could find no clinical internship program that would admit him... They lifted the requirement of a clinical internship. In its place, they set out a requirement that Dr. X practice under the supervision of a licensed psychologist for 2 years, or at least 1500 hours per year.

In many situations in the USA and Canada licensure and regulatory boards have designed rehabilitation plans without an independent outside assessment (Gonsiorek & Schoener, 1987). As such it is difficult to judge situations in which some sort of therapy and/or retraining and supervision have been prescribed and failed to prevent a reoccurrence of the offense. Margaret Bogie (personal communication), former Executive Director of the American Psychological Association Insurance Trust has expressed chagrin at the degree to which some prestigious practitioners with good reputations have been willing to vouch for offending practitioners as "cured" or "safe" after a course of therapy which was neither focused on the original offense nor part of a true rehabilitation plan. While in the cases she reviewed the subsequent offense typically did not involve a repeat of the original sexual misconduct, it did involve some sort of boundary violation or non-sexual misconduct.

More disturbing than cases involving professionals who have offended against adult clients have been those involving child or adolescent victims. In a surprising number of cases I have review from the 1970's and even the 1980's, a professional therapist or counselor with little or no experience with pedophilia has provided some sort of psychotherapy or counseling and then pronounced the offender as unlikely to reoffend. The most visible of such cases involved civil suits against churches which have typically focused attention on institutional negligence and cover-up, almost wholly ignoring careless work and decision - making by counselors and therapists who have issued these warranties (see for example Berry, 1992; Burkett & Bruni, 1993).

Despite the general disgust about pedophilia, health care professionals charged with sexual contact with children or adolescents often also get the "benefit of the doubt." In one, sexual contact with young boys by a pediatrician was ruled to be outside the scope of medical practice (and therefore not covered by professional liability insurance) even though it occurred in the doctor's office at the end of examinations. (Smith v. St. Paul Fire & Marine Ins. Co., 353 N.W. 2d 130, Minn. 1984, see also Bisbing, Jorgenson & Sutherland, 1995). In this case, Board of Medical Examiners was petitioned by a large number of signatories to not take away his license because of fear of losing their only pediatrician -- a sad consequence of the difficulty of rural America to find enough physicians. [While more shocking when it involves the abuse of children, community support for some offenders and opposition to efforts at regulatory board discipline are another problematic facet of the challenge presented by the abusive health care professional. Olsen (1989) provides a fine study of one such case, that of Dr. John Story, in his book DOC: The Rape of the Town of Lovell.]

Last but not least, in recent years regulatory bodies in North America have been experimenting with "boundaries training" and boundaries and ethics coursework to supplement, or replace personal therapy for offenders. This use of a broader range of interventions has been embraced by a major study done for the Maryland General Assembly (Nugent, Gill & Plaut, 1996). Recently debate as to the value and efficacy of this practice become a public issue in the New York Times Magazine story Dr. Smith Goes to Sexual-Rehab School (Abraham, 1995).

Misuses of Rehabilitation

While it might seem reasonable to presume that rehabilitation involves an attempt to alleviate conditions which led to the original misconduct so that the likelihood of a repeat offense is greatly lessened or eliminated, the term is often used to mean other things.

Hall (1986, p. 295) noted that members of psychology licensure boards in some states favor a "rehabilitation" approach because psychologists "that lose their licenses may practice under another title, without being subject to a professional conduct code and thus might cause more public harm." These observations are consistent with Brodsky's contention that:

"Rehabilitation as it is sometimes now practiced serves more as a minor form of punishment, perhaps to expiate the guilt of the offending therapist and, maybe even more, of the sanctioning committee or court. (Brodsky, 1986, p. 164)

Descriptions of licensure board actions in the literature do not describe rehabilitation plans that are based on formal assessments (see for example Sinnett & Linford, 1982). Plaut and Foster (1986) reported on the case of a therapist who had sexually abused several clients. He lost his license for a year, was referred for therapy and supervision, and agreed to some limitations on his case load. No mention is made of any formal outside assessment and the remedy is not characterized as rehabilitation, although it was obviously intended as such. All major task force studies, the most recent of which was done for the Maryland General Assembly (Nugent, Gill, & Plaut,1996) have concluded that this situation needs improvement.

While there is some literature on impairment in trainees and students, it is generally silent on sexual misconduct by trainees. This should not be surprising given the lack of attention paid to dealing with sexual feelings in the professional relationship (Schoener, 1989b) prior to some recent contributions (e.g. Edelwich & Brodsky, 1992; Epstein, 1995; Pope, Sonne, & Holroyd, 1993). Even today the literature provides scant evidence of training efforts which adequately address this issue -- a program at the Student Counseling Bureau at the U. of Calif - Davis (Rodolfa, Kitzrow, Vohra, & Wilson, 1990), a course at the Calif. School of Professional Psychology - San Diego (developed from a Ph.D. dissertation by Steres, 1992), and a most extraordinary course in the Psychiatry Residency Program at Jefferson Medical College in Phila. (Gorton, Samuel, & Zebroswki, 1996). Sanderson (1989), writing in connection with a major task force study, recommends that training programs utilize the same policies and procedures for trainees who have sexual contact with clients as are used for practicing professionals. Vasquez (1988), co-editor of an issue of the Journal of Counseling and Development devoted to the topic of therapist-client sex, takes the same position, recommending use of the assessment methodology described by Schoener and Gonsiorek (1988) in cases where trainees have had sexual contact with a client.

Objections to Rehabilitation

Some victims and victim advocates oppose rehabilitation, seeing it as a way of avoiding disciplinary consequences, or as not being sufficient to redress the harm done by the offender. Others, including some in the health care professions point to ill-fated efforts to treat and rehabilitate those who are not motivated, or are not able to change. I doubt that any among us would not challenge an attempt to rehabilitate a professional who did not: 1. admit guilt;   2. express remorse; &    3. indicate a strong desire to change.   Likewise, we would require a competent and thorough evaluation which found the practitioner/pastor to be, at least in theory, potentially treatable.

Beyond the concerns voiced about the lack or inadequacy of assessments and trying to treat people who are not treatable, one author, Pope, has authored numerous publications which unequivocally oppose rehabilitation aimed at returning to practice therapists who have had sexual contact with a client, going so far as to declare that this represents a violation of the Nuremberg Code developed in response to Nazi experiments (see for example Pope, 1990; Pope, 1994; Pope & Vasquez, 1991; Sonne & Pope, 1991). Allowing rehabilitation is presented as equivalent to a pesticide regulatory board member (who is charged with protecting the public) minimizing the risks of the pesticide chlordane (Pope, 1994, p.37).

In one study, based on responses to the question "Do you believe that therapy mandated by licensing boards as a condition of therapists continuing or resuming practice tends to be effective?," to which 34% of the respondents responded "absolutely yes" or "probably," Pope and Tabachnick concluded that:

The failure of research, theory, and other factors to convince more than a third of the professional community that such interventions by licensing boards are effective seems to warrant a rethinking of policy and practice in this area ..... (Pope & Tabachnick, 1994, p.255)

An examination of the data shows that 49.6% of the respondents indicated that they "don't know," while 12.2% indicated "probably not" and only 3.8% indicated "absolutely not," suggesting that about half of the field doesn't know enough to comment, or perhaps that the question is overly broad and presumes that one could generalize about something which needs to be determined on a case by case basis. To interpret the results as demonstrating a "failure....to convince" and to suggest that they "...warrant a rethinking of policy and practice..." (pp. 254-55) seems a somewhat convoluted way to view the data.

A keystone of this argument against rehabilitation is the repeated contention that there is supposedly an 80% "recidivism" rate among therapists who have had sexual contact with clients, with reference being made to Holroyd & Brodsky (1977) who found that 80% of a group of psychologists who acknowledged sex with clients indicated that it had been with more than one. A second citation is to "data" cited in a brochure developed by the California Dept. of Consumer Affairs (1990) which does in fact give the 80% figure, but correctly labels it as the percentage of therapists in one study who acknowledged repeat offenses. This is simply another reference to Holroyd & Brodsky (1977). No mention is made of a far more recent study which found that only one third of psychiatrists acknowledge repeat offenses (Gartrell et. al., 1987), or similar date from Australian (e.g. Leggett, 1984) or British work (e.g. Jehu, 1994). A citation is also made to Butler's (1975) Ph.D. dissertation which involved interviews with 20 therapists who admitted sex with clients, 75% of whom reported sex with more than one client, although 95% indicated that they did not want to do it again. It is unclear from the study whether this 95% who did not want to reoffend were, in fact, able to prevent a reoccurrence.

None of this data, of course, reflects on failed rehabilitation efforts per se. It does not represent "recidivism" in the usual meaning of the term -- that is, repeat offenses following some intervention (either punishment, rehabilitation, or both). As noted earlier, even the case cited by Bates & Brodsky (1989) where there was a repeat offense following licensure board action, involved a failure to require adherence to the original rehabilitation plan. (Questions were also raised about the judgment exercised by various parties including three different supervisors.) Beyond the inadequacies in execution, there is a serious question as to whether rehabilitation efforts were even warranted in this case in the first place.

Ironically, Pope (1989) himself has proposed a theoretical model for rehabilitation and even a methodology (Pope, 1987) for developing "extensive and reliable resources for coping with sudden or unanticipated risks and temptations that may occur in the future." I agree with some of Pope's cautions about rehabilitation as well as the importance of putting client safety first. However, in the absence of clear data to argue for across-the-board rejection of rehabilitation, I can see no reason to depart from the requirements of both the standard of care and ethics codes that require that cases be individually assessed and that any recommendations be based on an independent professional evaluation.

Beyond the dictates of professionalism, there are additional issues which can be raised about any approach which relies on this type of generalization or which seeks some "across the board" solution to such a multifaceted phenomenon. Dr. Glen Gabbard, Vice President of the Menninger Clinic, for example, writes:

...any attempt to understand the phenomenon of sexual misconduct requires a detailed examination of the characteristics of therapists who have become involved in sexual transgressions. A fair-minded and scientific assessment of these therapists has been hindered in recent years by the increasing politicization of the problem of sexual misconduct. In some segments of the mental health professions there is an insistence on a "politically correct" view of the phenomenon that ascribes all sexual misconduct to evil and thoroughly corrupt male therapists (Gabbard, in press; Gutheil & Gabbard, 1992). This perspective may have particular appeal to other practitioners of psychotherapy, who can reassure themselves that those colleagues who transgress sexual boundaries have characteristics that set them apart from all other therapists. The problem can thus be solved by eliminating these "bad apples" from the various professions.

This politically correct model depends on the projective disavowal of the universal vulnerability to sexual transgressions that is inherent in anyone who practices in the mental health professions. The most sensible approach is to assume that we are all at risk for boundary violations under certain circumstances..... All systematic studies of psychotherapists who have been involved in sexual boundary violations indicate that sexual misconduct occurs among a diverse group of clinicians who become involved with patients for a variety of reasons. Any attempt to lump all the transgressing therapists into one politically correct category is reductionistic and misguided. Gabbard (1994, pp. 438 - 439)

The belief that sexual misconduct cases are sufficiently different from all other types of professional misconduct so as to require a completely different response is based on faulty assumptions:

• That sexual misconduct is more harmful than other misconduct: While more than 50% of legal costs on behalf of psychologists in the U.S. are accounted for by sexual misconduct cases, categorizing these cases as "sex cases" does not mean that the sexual activity per se was the major cause of the damages. It has been acknowledged in many such suits that the mishandling of transference or other breaches of duty were key causes of damages and that damage would have been done even had the sexual contact not occurred (Bisbing, Jorgenson, & Sutherland, 1995). Nonsexual boundary violations per se can cause significant injury (Simon, 1992, 1995), and a great range of non-sexual misconduct is present in most "sex cases" (Schoener, 1989a). Poorly maintained professional boundaries, violations of confidentiality, business involvements with clients, providing services outside ones area of expertise, and many other negligent acts can and have caused serious harm. Professionals who violate trust in these ways require the same scrutiny as those whose misconduct includes sexual touch.

• That sexual misconduct is done predominately by sexual predators & compulsive sex offenders: While some who have sexual contact with clients are sexual predators, many are not (see for example Gabbard, 1995a,b; Gonsiorek, 1987, 1995a; Medlicott, 1968; Olarte, 1991; Schoener & Gonsiorek, 1988, 1989; Schoener, 1995b; Strean, 1993). As such, across the board comparison with the traditional prison sex offender population or other groups has little utility and no scientific justification.

• That there is some clear and generally accepted definition of sexual misconduct -- some clear place to draw a line between those who will be considered for rehabilitation vs. removed from the field forever: If there is to be only a single approach to "sexual misconduct cases," it would be critical to define what qualifies as a "sexual misconduct case." Does a single inappropriate hug which has some erotic elements which is followed by an apology from the professional and appropriate consultation meet the criterion for expulsion from the field? What about inappropriate sexual comments? How much resolved erotic transference & seductive talk before the line is crossed? These can be quite harmful in and of themselves. For example, is brief sexual contact in a single session, followed by apology and intervention, more serious than incompetent work accompanied by multiple non-sexual boundary violations?

• That a "type" of professional misconduct must have a clear-cut therapeutic prescription, which works across the board -- otherwise, NO rehabilitation can be attempted in any case. There is no established therapy for carelessness with confidential material, a tendency to work outside one's area of expertise, or a variety of other areas of professional misconduct, yet the field treats and disciplines offenders and attempts to train practitioners to avoid these problems.

• That the rehabilitated professional, returned to practice, must disclose his or her history of offenses to all potential clients or parishioners: The key issue following rehabilitation for any problem is whether rehabilitation was successful and whether anyone is are at risk. It is inappropriate to expect clients to assess such risks. The practitioner and any employer, ethics committee, or licensure board have the responsibility to make this determination and assure public protection. Otherwise, one could argue that a therapist would have to disclose other risk factors to potential clients such as: 1. any personal history of emotional problems; 2. current personal, emotional or relationship problems; 3. any past complaints of alleged professional misconduct; 4. personal financial problems. These all could lead to risk to consumers. Beyond the inappropriateness of expecting clients to make such determinations, the dynamics of the situation are such that it is an unrealistic expectation of the client. Ironically, the most disturbed and predatory of therapist-offenders would have no difficulty manipulating this requirement and turning such a disclosure to their advantage.

Since the beginning of the fields of psychotherapy and counseling, counselors and therapists have been treating colleagues for personal, marital and family problems which could impact on their work with clients. Outside of the disciplinary framework, professionals have sought help for personal problems which were impacting on their professional work, or which might impact on professional work. Only a small subset have come to the attention of regulatory bodies, and yet many may have averted more serious offenses through obtaining help after minor offenses or "near misses." Many of those who have sexually transgressed are on a continuum with others who have struggled with boundaries, or who are psychologically vulnerable. Boundary violation precursors to sexual misconduct are not infrequently the topic of supervision or psychotherapy of therapists, and these may also be the focus of rehabilitation efforts (Abel, Osborn, & Warberg, 1995; Epstein, 1994; Frick, McCartney, & Lazarus, 1995; Simon, 1995). When client welfare is of concern it is important that public safety play a role in the decisions being made. There are professionals who should not be practicing by virtue of serious impairments and who are not candidates for rehabilitation with current methods. As a matter of public safety, they should be removed from the field.

Remembering Our Own History

There is a tendency for many to want to distance themselves from the "bad apples" who have sexual contact with clients. It is convenient to see such people as a handful of sociopaths or fringe characters. Yet, many key contributors to the fields of psychotherapy and psychoanalysis have had a romantic or sexual involvement with a current or former client --- in some cases a client who was in training or already in the field him or herself (Gabbard, 1995c; Gabbard & Lester, 1995). Carl Jung had a romantic involvement with Sabina Spielrein, a young medical student who came to Jung struggling with serious emotional problems and then went on to a brilliant career in psychoanalysis, cut short by her murder by the Nazis on 27 July 1942. The historical record suggests that Jung helped her considerably, although doubtless also injured her. During a now famous interchange of letters with Freud, Jung acknowledged his misdeeds, only to have Freud blame Spielrein. (Kerr, 1993)

The involvement between June and Spielrein was not a singular one in early analytic circles:

Jung was scarcely the only person to become involved with a patient. Gross's exploits were legendary, Stekel had long enjoyed a reputation as a "seducer," Jones was paying blackmail money to a former patient, the even good Pastor Pfister was lately being entranced by one of his charges. Indeed, the most extraordinary entanglement was Ferenczi's, the amiable Hungarian having taken into analysis the daughter of the woman he was having an affair with and then fallen in love with the girl. Freud in fact was then currently seeing the younger woman at Ferenczi's request in an attempt to help rescue the situation. That Spielrein had once been Jung's lover would have disturbed Freud not at all. (Kerr, 1993, p. 379)

Freud's reference was to Ferenczi's involvement with Elma Palos (the daughter of his future wife Gisella Palos), whom both he and Freud had treated, in the now famous letter from Freud to Ferenczi of 13 December, 1931 containing Freud's criticism of Ferenczi's kissing of patients. (Mason, 1984; Rachman, 1993). Although this exchange is often used to suggest that Freud was a stickler on boundaries, the historical record shows otherwise Furthermore, Freud was providing private information to Ferenczi in an apparent attempt to influence his choice of a mate (Gabbard, 1995c; Gabbard & Lester, 1995). In addition, for many years the extent of Ferenczi's misconduct was not widely known because Ernest Jones' widely-read translation of this letter (Jones, 1957, p. 197), significantly, omitted Freud's attempt to connect the kissing of patients with what he termed Ferenczi's "old misdemeanors", "...the tendency to sexual playing about with patients..." (Mason, 1984, pp. 159-160). For his part Ferenczi replied to Freud in a letter dated 27 December 1931:

"The sins of youth," misdemeanors if they are overcome and analytically worked through, can make a man wiser and more cautious than people who never even went through such storms...Now, I believe, I am capable of creating a mild, passion-free atmosphere, suitable for bringing forth even that which had been previously hidden. (Mason, 1984, p. 160)

While at the University of Toronto, Ernest Jones became the subject of an allegation of sexual involvement with a client. He had not only initially denied the involvement but attacked the woman's general practitioner who had assisted her in making the complaint. However, his defense was seriously undermined by revelations that he had attempted to pay money to the former patient to stay quiet about the matter. (Gabbard, 1995c; Grosskurth, 1991)

The Memoirs of Margaret S. Mahler (Stepansky, 1988) revealed another example of an analytic and teaching relationship becoming sexual:

...my almost three-year analysis with Aichhorn, while helpful in many respects, was far from "classical." For the fact is that Aichhorn and I were, by this time, very much in love with one another, making impossible the classical relationship between analyst and analysand. In taking me under his wing and vowing to see me restored to the good races of the Viennese psychoanalytic establishment, Aichhorn only buttressed my self-image as an "exception" -- now in an entirely positive sense as opposed to the negative sense inculcated by Mrs. Deutsch. Under Aichhorn's analytic care, I became a sort of Cinderella, the love object of a beautiful Prince (Aichhorn) who would win me the favor of a beautiful stepmother (Mrs. Deutsch). At the same time, my analytic treatment with him simply recapitulated by oedipal situation all over again...

By the time Aichhorn intervened and secured my readmittance to the institute training program some six months after our analytic work began, I was his favorite pupil. As our personal relationship blossomed, I became his lover as well. (Stepansky, 1988, pp. 68-69)

Famous women analysts were also offenders. Frieda Fromm-Reichmann has written that her husband, Erich Fromm, was a patient when they became romantically involved, noting that at least they had the "common sense" to terminate the therapy before marrying (Fromm-Reichmann, 1989). [Even today, it is widely known but rarely discussed, that a number of key figures in the various psychotherapy fields are married to former patients.] Melanie Klein, who psychoanalyzed her own children, encouraged patients to come away with her on holiday and then provided therapy while they lay on her bed in her hotel room. (Grosskurth, 1986). [In terms of non-sexual boundaries, it should be noted that Freud analyzed his own daughter, Anna, who later indicated she felt exploited by many aspects of this process (Gabbard, 1995c), and Ernest Jones had Klein analyze his children and his wife (Grosskurth, 1991).]

Karen Horney is alleged to have had sexual relationships with candidates at the analytic institutes with which she was associated in both New York and Chicago, "including supervisees and analysands" such as "Leon Saul, who was traumatized by the experience" (Paris, 1994, p.142). She has been described at times as behaving much like the stereotype of the "dirty old man" who plays "sexual politics. "Horney's lovers sometimes became favorites to whom she gave power, until, to their pain and bewilderment, she turned against them. She then replaced them with other favorites.(Paris, 1994, p. 143)

Otto Rank reportedly became sexually involved with a former patient (Person, 1988). Freud himself encouraged Horace Frink, a young analyst whom he was treating, to follow his desires and divorce his wife so he could marry a patient (Gay, 1988). Gabbard (1995c) notes that Freud may have had financial motives in this case, hoping for a donation to the psychoanalytic movement from the patient's wealthy family, and that the outcome had some very negative consequences for those involved. He also challenges both the utility and the reality of efforts by those involved to distinguish transference love from love that occurs outside of the analytic relationship, an issue which persists in such cases today (Celenza, 1991).

Perhaps this should not surprise us. Reviewing even the earliest fumbling with the evolution of psychotherapy -- Joseph Breuer's treatment of Anna O.-- which Freud felt led to the development of the "talking cure, " the psychotherapeutic process, leads one to believe that clients often find their own way to health. According to Jones (1953), Anna O. developed a hysterical pregnancy. For his part, Breuer became entranced with this interesting client, leading his wife to become both angry and depressed. One night Anna O. went into a false labor and Breuer was obliged to visit her. According to Jones, he left her home in a cold sweat, went home, and the next day he and his wife left for Venice to spend a second honeymoon. (Jones, 1953, pp. 224-225) And what happened to Anna O., that troubled young woman? She grew up to be Bertha Pappenheim, a leading feminist, social reformer, and a pioneer in the field of social work in Germany (Swenson, 1994). True, the relationship with Breuer did not involve sexual activity, but it certainly involved heavy transference and countertransference, probably left unresolved.

Even as regards therapists who have had sexual contact with current or former clients, the historical record is clear that a number of offenders remained in the field, often with the blessing of key figures, and made major contributions before and after their offenses. It is also clear that they cannot be easily grouped into any one category. The fact that they had been intimate with a current or former client does not in and of itself permit inference of risk to others. To the degree that there was therapeutic intervention or rehabilitation, this was comprised solely of analysis or psychotherapy performed by persons untrained in dealing with therapist - sex offenders.

This is not to suggest that there should not have been a different type of intervention in each case, or to suggest that because the offender was a major contributor to the field that the sexual misconduct should be minimized or overlooked. But, by the same token separating out those who have had a romantic or sexual involvement with a client as uniquely dangerous, untreatable, and never worthy of return to the field flies in the face of our own history. Some are and some are not.

Discipline

Loss of a license, registration, certification, or job can be prescribed as discipline or punishment for sexual misconduct, quite apart from public safety concerns. The goals of discipline (or punishment) are typically the following:

• To reinforce a standard or underline the seriousness of an offense.

• To deter the offender from repeating his or her offense.

• To deter others from committing a similar offense.

• For justice and/or to maintain the integrity of the profession.

In most instances the question is NOT punishment versus rehabilitation. In fact, consequences may be a key ingredient in bringing about a successful rehabilitation. License suspension or leave from a job may be important for public protection until rehabilitation can be completed and judged as to its success. Disciplinary consequences and rehabilitation are not mutually exclusive. Rehabilitation should not be used as a mild form of punishment.

Who Are The Offenders?

The stereotypic image of the offender within the psychotherapy fields is:

A "dirty old man" who for years has been protected by the "old boys club" as he sexually exploits one female client after another, pausing occasionally to exploit graduate students and supervisees. He may engage in "sneaky" sexual touch during examination, cloak his sexual touching under the guise of treatment, or engage selected patients and/or students in long-term sexual relationships. When finally brought to justice he at first denies any wrongdoing then, trapped, admits to some of the behaviors but blames them on the client's alleged psychopathology or his situational vulnerability. He references his many contributions to the field, has supportive testimony from colleagues, and attempts to manipulate the situation so that he receives minor sanctions.

Certainly many aspects of this stereotype are to be seen in actual disciplinary cases everywhere (e.g. Quadrio, 1994), although in a recent study a number of psychiatrists presented as a defense that they were emotionally ill (Dawson, 1994). However, even with male offenders there is considerable variability. Pope and Bouhoutsos (1986, p. 4), apparently basing their observations on undesignated clinical experience, presented a classification based on what they described as "10 of the most common scenarios" of psychotherapists' sexual misconduct. These are described by Pope (1994, p.86) as [bold print is mine]:

1. Role trading (therapist becomes the patient);

2. Sex Therapy: sex fraudulently presented as "sex therapy";

3. As if wherein therapist ignores that feelings are likely to be transference;

4. Svengali (therapist exploits dependent client);

5. Drugs and/or alcohol used in seduction;

6. Rape (overt force or threats are used by the therapist);

7. True love (therapist rationalizes that it is "true love");

8. It just got out of hand (loss of control due to the emotional closeness of therapy);

9. Time out (therapist rationalizes that contact outside of session, is legitimate);

10. Hold me in which therapist exploits client's need to be held or touched.

While the scenarios described by Pope and Bouhoutsos (1986) and Pope (1994) are familiar ones, there are many other common ones as well. In addition to situations involving some sort of clear-cut exploitation, we have seen many which vary as to degree of sexual contact, apparent dynamics, and the degree to which the situation likely represents exploitation or predatory behavior versus a loss of control or some other phenomenon. During the past 25 years, consultation in more than 3,000 cases by the Walk-In Counseling Center has involved a great variety of situations, ranging from those with frank sexual exploitation, to others which are less clear-cut:

1. Cases involving romantic and/or erotic talk of a non-therapeutic nature which creates a great deal of fantasy about involvement, but no improper physical contact;

2. Cases involving a single episode of brief erotic contact, followed by an acknowledgement, an apology, and often the seeking of help from a consultant;

3. Cases involving the revelation that a therapist and spouse were formerly client and therapist many years earlier, but where the client/spouse has no grievance or complaint;

4. Cases involving same-sex erotic contact, during a hug, where the practitioner was not gay or lesbian-identified, and in which the professional was confused by the occurrence and immediately sought consultation;

5. Cases involving "old" complaints which involved conduct before the offender was professionally trained or licensed (e.g. at a time when he/she was a paraprofessional);

6. Cases involving use of touch which had been taught to the practitioner or trainee as part of a therapy approach, but which was high-risk and led to eroticized contact. The practitioner sought consultation after quickly realizing the inappropriateness of the resulting conduct;

7. Situations which occurred some time following a single brief professional encounter which was not considered a therapy or counseling session by either party. It also did not appear to have been a professional relationship to an outside consultant;

8. Involvements with friends of a client or a relative of a client, or with a client of another program in the facility -- which may not have led to complaints and whose propriety was difficult to judge & not a clear violation of any rule;

9. Inappropriate sexual humor in the case of a trainee or professional from another culture, which while troubling to the patient did not appear to be part of any pattern or attempt to introduce sex into the professional relationship.

10. Patient complaint of an improper interview where it appears that the major problem was the failure to properly explain why so much detail about the client's sex life was being sought. The interview was legitimate and done properly, but not adequately explained.

In short, there are a great variety of situations which have little in common with each other except that they involve sexual feelings on somebody's part, or the perception that there may be sexual or erotic feelings or touch.

Furthermore, although most discussion and theorizing has focused on the male professional - female client dyad, approximately 20% of our cases at the Walk-In Counseling Center have involved female - female contact, something quite surprising given the relatively low base rates for lesbianism.* Female professional - male client sexual contact accounts for about 5% and male - male about 5% of our sample. Self-report admissions of sexual misconduct by women professionals have increased dramatically in the more recent research literature (e.g. Committee on Physician Sexual Misconduct, 1992) and similar dynamics and client impact have been reported in female-female cases (Benowitz, 1991, 1994; Gartrell, 1992; Gartrell & Sanderson, 1994). Gay, lesbian, and bisexual therapists struggle with many boundaries challenges and some also have sexual contact with clients (Gonsiorek, 1995b; Lyn, 1995).

*Note: Given the fact that fields like psychology have only had a large influx of women practitioners in the last two decades, so that historically women professionals still account for a much smaller percentage of overall service hours, this percentage is quite high. British research (Jehu, 1994) has found largely female offenders involved heterosexually with male clients/patients, and the same is true for Germany (Becker-Fischer et. al., 1995), Australia (Leggett, 1994; Dawson, 1994), and data from Norway presented in Geilo in 1995 by Dr. Marina Hvistendahl. In nursing far more men than women acknowledge sexual activity with patients (Nursing '74). So, this high percentage for female-female relationships may be a North American phenomenon and also vary with the field of the professional.

The professional literature contains many observations about the personality and dynamics of the professionals who have some sort of sexual or erotic involvement with clients (Becker-Fischer et. al., 1995; Gabbard, 1994, 1995a,b; Nugent, Gill & Plaut, 1996; Quadrio, in press; Schoener et. al., 1989), and many authors during the past three decades have attempted to classify them (e.g. Apfel & Simon, 1985; Averill et. al., 1989; Medlicott, 1968; Olarte, 1991). There is broad agreement that this is a complex set of phenomena and a variety of personality types become sexual with clients.

Likewise professionals charged with sexual misconduct exhibit a great variety of responses to being charged and vary dramatically as to the degree they see themselves as wrongdoers (Pogrebin, Poole, & Martinez, 1992). This great diversity in offenders has been noted in studies done outside the United States (see for example Committee on Physician Sexual Misconduct, 1992; Jehu, 1994; Quadrio, 1992; Valentine, 1992). One report in the Australia & New Zealand Journal of Psychiatry, described a sample of 18 professionals who had sexually offended as falling into the following groups: 11% were psychotic, 11% were alcoholic, 6% were neurotic, and 44% had character disorders (Medlicott, 1968).

Cases studies of high visibility cases where sexual misconduct was alleged, or proven, have yielded widely varying pictures of the professional who is the subject of the complaint. In one lawsuit (Walker vs. Parzen), although the doctor claimed situational vulnerability played a key role in what transpired, a detailed psychological profile of the therapist/defendant revealed a man with chronic and serious emotional disturbance (Walker & Young, 1986). Recent accounts of the case of Dr. Margaret Bean-Bayog, where sexual contact may or may not have occurred, but where erotic fantasy was rampant, focus on difficulties managing transference and countertransference (Chafetz & Chafetz, 1994; McNamara, 1994). Still other cases seem linked, in part, to organizational forces within psychotherapy cults rather than just individual pathology (Mithers, 1994; Schoener & Milgrom, 1989).

Cognitive-Behavioral Approaches

More traditional sex offender treatment programs have been a resource for some professionals who have engaged in sexual misconduct for some years now. Until recently little has been published on their extensive work with professionals who have engaged in sexual misconduct. Typically they tend to focus their evaluation on identification of sexual impulse control disorders as presented in the DSM IV. Since some professionals who have offended against clients do not show the same compulsive behaviors as other sex offenders, these programs take into account the behavioral circumstances of the offense(s) in an effort to devise a rehabilitation strategy. As such, work such as that of Abel and colleagues focuses on "developing skills to decrease arousal, including the development of safeguards to attempt to prevent the professional from ending up in a high risk situation again," paralleling the authors' work with other types of sex offenders but extending it considerably (Abel, Barrett, & Gardos, 1992; Abel, Osborn, & Warberg, 1995).

The cognitive behavioral approach has been researched extensively, although its application to professionals who have offended is more recent and not as well researched. Psychophysiologic measures such as the penile plethysmagraph may be utilized in diagnosis or evaluation of treatment outcomes. Typically a period of evaluation and intensive treatment is followed by a structured aftercare program, including cognitive-behavioral therapy, re-education, and a strong emphasis on relapse prevention. Examples of re-entry plans and procedures are available in the literature. (Abel, Osborn, & Warberg, 1995; Abel & Osborn, in press). In general those who utilize this approach have a tendency to believe that many offenders can be returned to practice with sufficient followup safeguards.

Psychodynamic Approaches

Strean's (1993) recent book Therapists Who Have Sex With Their Patients: Treatment and Recovery does not rely on any sort of typology. The four cases he presents are described as:" A macho psychiatrist afraid of the "woman" within"; "A psychoanalyst who administers expensive love therapy"; "A sex addict who believes his women patients hunger for him"; an "A sadomasochistic social worker who makes his female ex-patients suffer." The overall approach is psychodynamic and individualized. One of the three cases involves a female therapist. Claman (1987) and others have also presented cases analyzed from a dynamic or psychoanalytic perspective.

Gabbard (1994, 1995a,b), based on extensive clinical experience with offenders at the Menninger Clinic in Topeka, Kansas, sorts offenders into four groups:

• psychotic disorders
• predatory psychopathy and paraphilias
• masochistic surrender -- a "giving in" to a challenging or difficult client, hoping to mollify the client by being flexible with boundaries
• "lovesick" -- within the "lovesick" category he notes a number of issues which singly, or in multiples, play a role in the misconduct:
  • Unconscious reenactment of incestuous longings
  • A wish for maternal nurturance is misperceived as a sexual overture
  • Interlocking enactments of rescue fantasies
  • Patient viewed as idealized version of self
  • Confusion of therapist's needs with patient's needs
  • Fantasy that love, in and of itself, is curative
  • The exception fantasy
  • Repression or disavowal of rage at patient's persistent thwarting of therapeutic efforts
  • Anger at organization, institute, or training analyst
  • Manic defense against mourning and grief at termination
  • Insecurity regarding masculine identity
  • Patient as transformational object
  • Settling down the "rowdy" man (the notion that the "right woman" can fix even the most character disordered man)
  • Conflicts around sexual orientation

Treatment efforts are focused on the "lovesick" category as well as those in the "masochistic surrender" grouping which includes therapists with masochistic and self-destructive tendencies who essentially allow clients to intimidate or control them. The psychotics and the predators are not deemed good subjects for rehabilitation insofar as treatment is aimed at a return of the practitioner to practice in psychotherapeutic work or in work which allows for private contact with patients.

Sexual Addiction

Another approach to classification has grown out of the work on sexual addiction (Carnes, 1983, 1991). This literature has been rapidly expanding in recent years (e.g. Blanchard, 1991; Graham, 1991; Irons & Schneider, 1994; Irons & Schneider, in press). While the typical sexual addiction program seeks to identify addictive or compulsive aspects of sexual behavior and classifies a wide range of individuals into this single category, a more complex theoretic base has been developed by Irons (1991, 1994). This model presumes that some professionals who engage in sexual misconduct do not have a paraphilia or psychosexual disorder as defined in DSM IV. The model takes into account the parallels with incest in such relationships and relates the acting out behavior to an attempt to cope with inner wounds (they report a high percentage of abuse victims among the professionals they evaluate). They also frequently find other addictions to be present (Irons & Laaser, 1994).

Extending the addictions approach, Irons (1995) presents a set of "archetypal categories" which are reminiscent of a Jungian approach to personality, and attempts to use them to further describe offenders. Irons & Schneider (1994) found the following when they applied these categories to a sample of 88 sexually exploitative health care professionals they found different percentages fell in each group, and that the percentage in each category who was diagnosed with sexual addiction also varied considerably:

The naive prince -- early in career, feels invulnerable, tends to develop "special relationships" with certain types of clients & blurs boundaries [7.9% overall but none of the sex addicts in this category]

The wounded warrior -- overwhelmed by demands, overly dependent on professional mantle for validation--patient involvement=temporary escape [21.6% overall, with 37% in this category judged to be sex addicts]

The self-serving martyr -- middle or late career; work is primary; withdrawn, angry, and resentful [23.9% overall, with 62% in this category judged to be sex addicts]

The false lover -- enjoys living on the edge, the "thrill of the chase"--a risk-taker who desires adventure [19.3% overall, but with 94% in this category classed as sex addicts]

The dark king -- powerful & charming; successful, manipulative--sexual exploitation as an expression of power [12.5% of sample, but 91% in this category were diagnosed as sex addicts]

The wild card -- erratic course in person & professional life; significant difficulties in functioning--has major Axis I disorder [14.8% of the total sample, with only 23% judged to be sex addicts]

The assessments done utilizing this approach are inpatient assessments for the most part. The presumption is that the intensity of the evaluation and milieu will penetrate denial and other defenses and reveal the underlying problems. This approach can be utilized with a resistant person who does not fully acknowledge the degree of dysfunction. Irons' work has continued to evolve and he has developed a typology for hostile and aggressive professionals and has also moved his work to the Menninger Clinic in Topeka Kansas (Personal communication).

Gonsiorek/Schoener Typology

The final approach is the one developed by myself and John Gonsiorek (Gonsiorek, 1987, 1989, 1995a; Gonsiorek & Schoener, 1987; Schoener & Gonsiorek, 1988, 1989). (Gonsiorek is former Clinic Director at the Walk-In Counseling Center but for a number of years has been in private practice of both clinical and forensic psychology in Minneapolis.) While this assessment methodology does not focus on sorting offenders per se, the categories were created to to serve an educational purpose:

1. Psychotic & Severe Borderlines: Underlying psychiatric disorder is source of impulse control problems. Delusional thinking present in some cases.

1a. Manic disorders: Manics, who when they go off their medication, engage in very impulsive, and at times sexual, behavior

1b. Organic or toxic psychoses: secondary to brain damage, senility, steroid intoxication, etc.

2. Sociopathic and Severe Narcissistic Personality Disorders: Self-centered exploiters, entirely focused on their own interests and needs; often adept at manipulation, and of talking their way out of trouble.

3. Sexual Impulse Control Disorders: Every variety of sexual impulse control disorder can be seen in the professional office, characterized by compulsive behavior, seeking sexual gratification or control and power.

4. Chronic Neurotic & Isolated: Very emotionally needy, they become overly involved with their clients/parishioners and eventually the relationship becomes sexual. Not originally driven by sexual needs.

5. Situational Offenders Good professional history and generally emotionally healthy but with a situational breakdown in judgment or control (Note: There are situational factors in most cases; but to be in this category psychopathology has to be ruled out)

6. Naive -- difficulty understanding and operating within professional boundaries due to deficit in social judgment (in the absence of psychopathology); may not have the social judgment necessary to be a professional

The overall approach used is a rule-out approach--the assessor attempts to rule out serious pathologies (categories 1, 2, & 3). If the offender is probably in categories 4, 5 or 6 then the dynamics of the situation may be of importance. The assessment involves a parallel assessment of both professional history and functioning and personal history and functioning.

Perhaps the most unique feature of this approach is the emphasis on attempting to gain detailed background data through an interview of the victim or complainant. It is our belief that this greatly enhances our ability to understand the situation for at least three reasons:

Much like the situation with visual perception where one needs two eyes to see in three dimensions, and where the discrepancy between the view granted by each of ones eyes creates the three dimensional view, having information from both parties provides a much richer picture. This combines traditional psychological assessment which seeks to predict behavior from personality with the approach utilized by criminal profilers who seek to predict personality from behavior under the principle, that to know an artist one would do well to examine his work (see for example Douglas & Olshaker, 1995).

Common Features of Assessments

Despite the substantial differences in approach, as compared with traditional psychological evaluation, each of these assessment methodologies involves the collection of far more background data from persons other than the person being assessed. Each involves obtaining of behavioral description of the events in question and each one requires a good deal of cooperation. Each approach recognizes that some offenders lie or minimize, and also that some will seek these assessments in order to attempt to avoid consequences. Each believes that some offenders cannot be rehabilitated and recognizes the need to counsel some people out of the field.

Each pays some attention to the dynamics of the professional relationship and assumes multiple determinants in the typical case. Each presumes that public safety is a key issue, and each involves an initial diagnostic decision, a treatment plan, and an eventual evaluation after treatment is concluded to assess whether it was successful.

All of these approaches presumes that professional retraining of various types may be necessary and that skill and training issues may be as important as psychopathology in some cases. However, as was noted by several speakers at a symposium on "Sexual Misconduct: Therapist Evaluation and Rehabilitation" at the 1994 Annual Meeting of the American Psychiatric Association (Lazarus, 1994), "knee jerk" referrals for retraining or supervision are no more useful than referrals for therapy. One needs to be quite specific as to what deficits in skills or training are present and why the specified course of retraining is expected to remedy the situation.

Each involves the use of supervision and the development of a re-entry plan with possible practice limitations. However, all stress the importance of clearly defining the supervision. It is critical that its goals and requirements be spelled out in detail, and that case consultation (voluntary sharing of clinical material, often termed "supervision") be differentiated from true supervision wherein the supervisor is legally responsible for the practice oversight.

In recent years some licensure boards have taken to requiring "ethics consultation" which involves regular meetings, often monthly, with an "ethics consultant." It is unclear what this is expected to accomplish in that in most misconduct cases there was no lack of understanding of professional ethical standards. In fact, I have seen this required of professionals who teach ethics or have served on ethics committees and are very knowledgeable about the codes. As was noted earlier in this paper, "boundaries training" has also been added to the rehabilitation options (Abraham, 1995), but again this is often not clearly connected to a rationale based on why the misconduct occurred. Even referrals for ethics coursework, meetings with an ethics consultant, or boundaries "training or coaching" should have their justification in the findings of an independent assessment. There is no less rationale needed for such a referral than for a referral for therapy.

Difference Between Models

A number of these models typically lead to a specific treatment approach. Gabbard's involves psychodynamic therapy or psychoanalysis and Iron's typically involves treatment for an addiction of one type or another. Abel's model is focused on cognitive-behavioral therapy and may utilize some psychophysiological instrumentation. Our model is not particularly tied to any given therapy approach, although Gonsiorek (1987, 1989, 1995a) has articulated his own approach to therapy with some offenders.

Note that all of these models presume practice limitations and/or supervision of practice, even when rehabilitation appears to have been effective. All aim at identifying risk situations so that supervision can be targeted. A detailed discussion of supervision issues can be found in Schoener et. al. (1989) which has four chapters devoted to supervision. It is important to note that when a rehabilitation plan involves retraining through, for example, an internship, that in many communities an offending professional undergoing rehabilitation may not be able to find a site for such retraining. If this is the case it may mean that rehabilitation, while theoretically possible, cannot be accomplished. The most common licensure board error is relenting on such a requirement when the practitioner cannot find anyone willing to truly supervise (and thus be legally liable for) his work. Issues in supervision of practitioners who have engaged in misconduct have become a topic of discussion in the profession (see for example, Abel, Osborn, & Warberg, 1995; Frick, McCartney, & Lazarus, 1995; Gabbard, 1995b; Irons, 1991; Lazarus, 1994; Nugent, Gill & Plaut, 1996).

Legal risks in rehabilitation and subsequent supervision of impaired practitioners have also been discussed in recent literature (e.g. Bisbing, Jorgenson & Sutherland, 1995; Jorgenson, 1995) as have the transference and countertransference challenges in treating such therapists (Gabbard, 1995b; Gabbard & Lester, 1995). If one makes a mistake and subsequent clients are injured there can be serious consequences via a loss of professional credibility and damages in a professional liability suit.

While a discussion of risk management and prevention go beyond the scope of this paper, it is perhaps worthy of note that some educational and therapeutic interventions aimed at prevention (e.g. Pope, 1987) and some institutional risk management approaches (e.g. Menninger, 1991; Schoener, 1995c) mirror procedures utilized in rehabilitation plans and re-entry plans.

It should be obvious, but simply completing counseling, therapy, or retraining is not sufficient to prove that rehabilitation has been accomplished. The question is whether the goals were attained, and the needed changes made. As a practical matter there are many outcomes beside successful completion of rehabilitation:

It is important to make an overall assessment of the success of the rehabilitation effort. In the end the evaluator must put him or herself on the line as regards potential future risks to consumers. When one is doing the re-evaluation for field re-entry one should be prepared to answer at least two key questions:

If you can't answer these questions with a sense of personal conviction, then the job isn't done. If this practitioner is not trustworthy enough to work with your friends and family, he/she shouldn't be rendering services to others' families.

A Note on Pedophilia

True pedophilia is quite difficult to treat and is often difficult to diagnose because offenders don't always tell the truth. In the case of an involvement with and older adolescent client it may be that the young person was being used as an adult surrogate. However, with young children pedophilia is quite likely. Where there is a significant question as to whether one is dealing with a pedophile we recommend consideration of the use of psychophysiologic testing (e.g. plethysmography). We are impressed with the early, though unpublished data on the Abel Screen developed by Dr. Gene Abel of the Behavioral Medicine Institute of Atlanta and recommend an assessment there when this question arises. The Screen is less intrusive and less offense than some other methods of testing.

Specialized Programs

While most therapists and settings do not have a sufficient number of offending professionals to form groups which are exclusively professionals (as has been done with substance abusing professionals, for example), some programs are developing a large enough population to do so. In some states sexually abusing physicians meet with physicians with other types of impairment. The earliest models were centers developed for the treatment of clergy with impulse control problems -- e.g. Servants of the Paraclete (Jemez Springs, New Mexico); House of Affirmation (Boston), St. Luke's Hospital (Suitland, Maryland); St. Barnabas Center (Wisconsin) -- although some of these have had an unstable history. All but St. Luke's have now closed and are no longer treating impaired clergy, although there are a number of programs in the United States which still do specialize in treating impaired clergy. However, programs for health care professionals struggling with addictions are developing programs aimed at evaluation and/or treatment of professionals who sexually offend.

It is likely that more specialized programs and support groups will be available in the future. However, it is important to note that the diversity within the group of professionals who have had sexual contact with clients is quite dramatic. Thus it is not likely that a single type of support group will be universally helpful.

It has been our experience that with the proper mindset, orientation, and general assessment skills an experienced clinician can do a competent assessment of rehabilitation potential. Our staff has often provided consultation over the phone to clinicians doing their first such assessment and been impressed by the fact that careful work can bring about useful findings. While experience assessing impaired professionals is helpful, it is not essential to be able to do a competent piece of work. It should be noted that this assessment strategy can be utilized with non-sexual boundary problems and other problems of professional practice.

A three hour symposium chaired by Dr. Jeremy Lazarus on the topic of assessment and rehabilitation took place at the 1994 Annual Meeting of the American Psychiatric Association (Lazarus, 1994). It is available on audiotape (see references). The February 1995 issue (vol.25, no. 2) of Psychiatric Annals contains a number of articles by the same presenters (Abel, Osborn, & Warberg, 1995; Frick, McCartney, & Lazarus, 1995; Gabbard, 1995b; Jorgenson, 1995; Schoener, 1995b; Simon, 1995). On the overall issue of sexual misconduct by professionals, Steven Bisbing, Linda Jorgenson, & Pamela Sutherland (1995) have provided an extraordinary resource in their new text Sexual Abuse by Professionals: A Legal Guide which contains an in-depth review of the psychological literature and goes far beyond the typical legal text. A recent public-policy related examination of these issues was published in the Report of the Maryland Task Force to Study Health Professional-Client Sexual Exploitation -- Sexual Exploitation: Strategies for Prevention & Intervention (Nugent, Gill, & Plaut, 1996).

References

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