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.
This is a portion of a talk entitled “Boundary Violations in the Professional Relationship: With Special Focus on Sexual Abuse of Clients – Ethics, Damage, & Prevention” presented at the Department of Psychology, University of Oslo, Norway, 5 September 1997. Edited by AdvocateWeb, with permission from the author.
Long before inappropriate intimacy or sexual contact occur in a helping relationship, a variety of boundary crossings or violations often occur. (Simon, 1995) Inappropriate touch is only one variable, and is not the most common. We are not simply talking about erotic touch. These represent breakdowns in the professionalism of the relationship and, as such, often undermine the therapy.
Enmeshment of the client in a relationship characterized by unidentified or unresolved erotic transference & counter-transference may be at times more harmful and confusing than having sexual contact with them. The same can be true with intense friendships which confuse the counseling or make the client unnecessarily dependent on the helper. Even romantic “game playing” can be quite distracting and harmful. Even without overt sexual contact, boundary breakdowns can lead to damages similar to those seen when the relationship becomes sexual (Schoener et. al., 1989, pp. 133-147; Simon, 1991):
• The failure to render needed therapy — undermining what good work may have been done;
• Failure to refer for other services — the psychotherapist “hanging on” to the client and trying to provide for all of his or her needs;
• Creation of unhealthy dependency which is difficult to resolve;
• Confusing the client about what is therapy and what is personal;
• Breach of trust — client distrusting professionals as a result of the corruption of the therapy;
• In some instances, interference in family relationships, friendships, etc.
• Anger, loss of self esteem, depression, and other psychological distress.
The research has failed to show that practice style per se is the major issue in boundary breakdowns, boundary crossings, and whether or not the relationship is sexualized. Psychoanalysts become sexually involved with clients despite the fact that they don’t do much touching, and many body-therapists (e.g. Reichian) do not have difficulties in this area.
Even separating psychotherapists along lines of boundary conservativeness versus risk taking does not clearly separate those who have sexual contact with clients from those who do not. Borys (1988) compared those who admitted to sex with clients to those who didn’t on a number of self-reported boundaries issues. Despite the fact that 40 of her 44 offenders had a post-termination sexual relationship (which one would expect would have caused high scores on her scale), she could only correctly classify 55% of the erotic practitioners and 79.4% of the non-erotic when comparing them on her “Social Involvement Scale,”which included the following items:
• Became friends with client after termination
• Disclosed details of your current personal stresses to a client.
• Invited clients to an office/clinic open house
• Went out to eat with a client after a session
• Invited clients to a personal party or social event
There is considerable variability in the psychotherapy fields, as well as within any given field (e.g. psychology), as to what is acceptable in some boundaries areas. Borys (1988) found, for example, in a national survey of psychologists, psychiatrists, and social workers:
Accept a gift under $10: 19.5% never 53% several 10.4% all clients
Accept invitation to client’s special event: 50% never 22% few 3.4% some
Becoming friends after termination: 65% never 23% few 3.3% several clients
Treating an employee: 57% never 12.8% few 3% some clients
Disclose own stresses to client: 59% never 26.8% few 9.7% some 1.3% many
Invite to open house: 50% never 5.7% few 6.7% some 2.7% many 3.4% all
As regards attitudes towards erotic touch, or touch in general, the Norwegian study cited earlier found the same thing as American studies have: you cannot clearly differentiate offenders from non-offenders on these dimensions.
Excessive Self Disclosure by the Psychotherapist
Therapist self-disclosure is by far the most common boundary violation which precedes sexual involvement with clients as well as a number of other therapeutic mistakes. Therapist self-disclosure is problematic when it involves:
• Disclosing current personal needs or problems;
• Disclosure as common, rather than rare event, during sessions;
• Disclosing things not clearly connected to client’s problems or experiences; or not clearly things which would be likely to encourage or support client;
• Self-disclosure not only frequent, but uses up more than a few minutes in a session
• Self-disclosure occurs despite apparent client confusion or romanization.
Self-Reflection & Supervisory Oversight
From the organizational perspective, several references focus on organizational issues: Psychotherapists’ Sexual Involvement With Clients: Intervention & Prevention (Schoener et. al., 1989, pp. 451 -516), The Incestuous Workplace: Stress & Distress in the Organizational Family (White, 1997), and Breach of Trust (Gonsiorek, 1994, pp. 176-192, 284-316).
At the level of the individual psychologist, Epstein’s (1994) Keeping Boundaries: Maintaining Safety and Integrity in the Psychotherapeutic Process and Gabbard & Lester’s (1996) Boundaries and Boundary Violations in Psychoanalysis are excellent. In the area of sexual feelings, Rutter’s (1989) Sex in the Forbidden Zone. In the area of sexual misconduct, Pope, Sonne, & Holroyd’s (1993) Sexual Feelings in Psychotherapy, and Edelwich & Brodsky’s (1991) Sexual Dilemmas for the Helping Professional are useful. So is Marilyn Peterson’s (1993) At Personal Risk. Epstein & Simon (1992) have developed an “Exploitation Index” for clinicians to use to evaluate their own boundary maintenance.
Some areas which require self-awareness and watchfulness by ones’ supervisors or consultants, are:
• Obvious therapist distress or upset
• Therapeutic drift — shifting style and approach to a given client
• Lack of goals and reflection on progress in therapy
• Therapy which exceeds normal length for a client of that type in the particular therapist’s practice.
• Exceeding areas of competence, reluctance or unwillingness to refer for other types of therapy, assessment, etc.
• Unwise techniques:
o Routine hugs
o Face to face, intimate hugs
o Excessive touch
o Sessions in non-traditional setting when this isn’t necessary
o Adult clients on lap
o Routine or common socializing with clients
o Excessive self-disclosure by therapist
o Direct intervention in client’s life
• Becoming enmeshed in client’s life — treating close friends or family members
• Unique vulnerabilities:
o Over-identification with client
o Uniquely similar family dynamics
o Divorce or loss in therapist’s life
o Identity disturbance in therapist
Dynamics Which Make Psychotherapy a Potential Setting for Boundary Violations and Exploitation
• It involves a fiduciary relationship with unequal power, especially early in the relationship. The therapist sets all the rules and the therapy is conducted in private so there is little accountability.
• A variety of common dynamics seen in cases of exploitation (e.g. see Gabbard, 1994):
o Unconscious re-enactment of incestuous longings;
o Wishes for nurturance can emerge & be quite powerful;
o Rescue fantasies — the countertransference trap of doing a better job than someone’s parents or previous therapist/counselor;
o Fantasy that love, or sex, are curative in and of themselves;
o Repression or disavowal of rage at client’s persistent thwarting of your therapeutic efforts;
o It is a fertile ground for acting out anger at organization, supervisor, etc.
o Defense against grief and mourning at termination;
o It is an unreal world — the “exception” fantasy;
o A “safe” ground to experiment — e.g. sorting out identity confusions:
o Cultural myth that the “right woman” can fix the most disordered man
Prevention Aids — Training
A. BOUNDARIES EXERCISES (see Jeanette Milgrom’s  BOUNDARIES IN PROFESSIONAL RELATIONSHIPS)
B. PRACTICE WITH CLIENT CHALLENGES TO BOUNDARIES — Lisa Steres’ videotapes and role plays [Lisa Steres, Ph.D. Scripps Clinic Rancho Bernardo, 15025 Innovation Drive, San Diego, Calif. 92128(619) 487-1800]
C. WORK ON THE TASKS INVOLVED IN TERMINATION WITH A CLIENT AND ON POST-TERMINATION ISSUES
D. VIDEOTAPE PACKAGES: There are a number aimed at clergy & pastoral counselors, but recently Hazelden has produced one entitled SUBTLE BOUNDARY DILEMMAS. [Available from Hazelden, Box 176, Center City, Minn. 55012-0176. Phone orders from US & Canada: 1(800) 328-9000 with credit card.] The Assn. of State & Provincial Psychology Boards has one on ETHICAL DILEMMAS FOR PSYCHOLOGISTS [ASPPB, P.O. Box 4389, Montgomery, Alabama 36103. Call 1(800) 448-4069 — hope to be able to take phone orders with credit cards soon.]
Borys, D. (1988) Dual relationships between therapists and client: A national survey of clinicians attitudes and practices. Unpublished doctoral dissertation, UCLA.
Committee on Physician Sexual Misconduct (1992). Crossing the Boundaries. Vancouver, British Columbia: College of Physicians and Surgeons of British Columbia.
Dawson, E. (1994). Professional misconduct in psychiatry: sexual behavior with patients. A report of recent New South Wales findings. Australian & New Zealand J. of of Psychiatry, 28, pp. 197-204.
Edlewich, J. & Brodsky, A. (1991) Sexual dilemmas for the helping professional. N.Y., N.Y.:Brunner/Mazel
Epstein, R. (1994). Keeping boundaries: Maintaining safety and integrity in the psychotherapeutic process. Washington, DC: American Psychiatric Press.
Epstein, R . & Simon, R. (1992) The exploitation index. Bulletin of the Menninger Clinic, 56, pp. 1 – 21.
Fromm-Reichmann, F. (1989). Reminiscenses of Europe. In A. Silver (Ed.) Psychoanalysis and Psychosis pp.469-481. Madison, Conn.: International Universities Press, pp. 469-481.
Gabbard, G. (1995). The early history of boundary violations in psychoanalysis. J. of the American Psychoanalytic Assn., 43, pp.1115 – 1136.
Gabbard, G. & Lester, E. (1995). Boundaries and Boundary Violations in Psychoanalyisis. New York: Basic Books.
Gay, P. (1988). Freud: A Life for Our Times. New York, N.Y.: Norton.
Gonsiorek, J. (Ed.) (1995). Breach of Trust: Sexual Exploitation by Health Care Professionals and Clergy. Thousand Oaks, Calif.: Sage.
Grosskurth, P. (1986). Melanie Klein: Her World and Her Work. New York: Alfred Knopf.
Grosskurth, P. (1991). The Secret Ring: Freud’s Inner Circle and the Politics of Psychoanalysis. Reading, Mass.: Addison – Wesley.
Jehu, Derek. (1994). Patients as Victims: Sexual Abuse in Psychotherapy and Counselling. Chichester, England: John Wiley & Sons.
Jones, E. (1957). The Life and Work of Sigmund Freud, Vol. 3. New York, N.Y.: Basic Books.
Kerr, J. (1993). A Most Dangerous Method. New York, N.Y.: Alfred A. Knopf.
Mason, J.(1984). The Assault on Truth. New York, N.Y.: Farrar, Straus & Giroux.
Milgrom, J. (1992) Boundaries in professional relationships. Mpls., Minn.: Walk-In Counseling Center.
Paris, B. (1994). Karen Horney: A Psychoanalyst’s Search for Self Understanding New Haven: Yale University Press.
Person, E. (1988). Dreams of Love and Other Fateful Encounters: Romance in Our Time. New York, N.Y.: Norton.
Peterson, M. (1993) At Personal Risk. NY, NY: W.W. Norton
Pope, K., Sonne, J., & Holroyd, J. (1993). Sexual Feelings in Psychotherapy. Washington, DC: American Psychological Association.
Rachman, A. (1993). Ferenczi and sexuality. In L. Aron & A. Harris (Eds.) The Legacy of Sandor Ferenczi, pp. 81 – 100, Hillsdale, N.J.: The Analytic Press.
Rutter, P. (1989). Sex in the Forbidden Zone. Los Angeles, CA: Jeremy Tarcher.
Schoener, G., Milgrom, J., Gonsiorek, J., Luepker, E., & Conroe, R. (1989). Psychotherapists’ Sexual Involvement With Clients: Intervention and Prevention. Minneapolis, MN: Walk-In Counseling Center.
Schwebel, M., Skorina, J., & Schoener, G. (1994). Assisting Impaired Psychologists.Revised Edition Washington, D.C.: American Psychological Assn.
Simon, R. (1991). Psychological injury caused by boundary violation precursors to therapist-patient sex. Psychiatric Annals, 21, pp. 614-619.
Simon, R. (1995). The natural history of therapist sexual misconduct: Identification and prevention. Psychiatric Annals, 25(2), pp. 90-94.
Stepansky, P. (Ed.). (1988). The Memoirs of Margaret Mahler. New York, N.Y.: Free Press.
Steres, L. (1992). Therapist/Patient sexual abuse and sexual attraction in therapy: A professional training intervention. Unpublished doctoral dissertation, Calif. School of Professional Psychology — San Diego.
Swenson, Carol (1994) Freud’s “Anna O.”: Social work’s Bertha Pappenheim. Clinical Social Work Journal 22(2), pp. 149-163
White, W. (1997) The incestuous workplace: Stress and distress in the organizational family. Center City, Minn.: Hazelden Foundation
White, W. (1993) Critical incidents. Bloomington, Ill.: Lighthouse. [available from Lighthouse Training Inst., 702 W. Chestnut, Bloomington, Illinois 61701. (309) 827-6026]
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