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Collapsing into Sexuality: The Dynamics of Sexual Boundary Transgressions by Therapists

woman in bedAndrea Celenza’s bibliography is all about sex. Mostly sex between therapists and their clients. Curiously, for therapists, whose theoretical legacy is strewn with references to the sexual engine room of psychic life, this appears to be something of a taboo subject.

And it is this repression of the subject of sexual boundary transgressions that Celenza believes is to account for the messes in which psychologists find themselves when they fall into sexuality with their clients.

New Therapist spoke exclusively to Celenza about sexual boundary transgressions, the dynamics beneath them and how therapists salvage their clinical and professional identities after such breaches.

New Therapist (NT): You have made the point that the denial of the vulnerability of therapists to sexual boundary transgressions amounts to a kind of splitting or denial that in itself makes one vulnerable to such transgressions. Do you think that, as a professional grouping, therapists and their ilk are inclined to downplay the risk and likelihood of such transgressions?

Andrea Celenza (AC): I do think therapists and other mental health professionals have a tendency to downplay the emotional risks and psychological effects of doing our work. This is part of the vulnerability that makes us all more likely to engage in transgressions.

I wrote about this in a paper entitled, “The Analysts’ Needs and Desires” (which can be downloaded for free from my website http://www.andreacelenza.com). In this paper, I emphasize the necessity for self-care—basically, healing ourselves so that we are prepared to heal others. Most importantly, self-care needs change and become more important as we age, especially if we are becoming burnt out or have other stresses in our lives.

The denial of vulnerability comes from three sources (primarily):

a) our tendency to neglect ourselves and focus on problems in others;

b) our tendency toward a kind of grandiosity and self-aggrandizement—‘we don’t have problems, others do;’ and finally,

c) a common misconception that sexual boundary transgressions are only committed by psychopaths, the true bad apples that need to be weeded out of any profession.

This latter misconception couldn’t be further from the truth; the great majority of transgressors are so-called ‘one-time transgressors’ who have genuine remorse and are generally high functioning people.

NT: Are you able to provide some kind of figures that demonstrate how prevalent sexual boundary transgressions are among psychotherapists?

AC: Here’s some data elaborated in my book (Sexual Boundary Violations: Therapeutic, Supervisory and Academic Contexts) that spells out the prevalence: Prevalence studies consistently reveal an unacceptably high incidence rate (7–12%) of erotic contact between therapists and patients among mental health practitioners in the United States.

All of these studies are comprised of anonymous, self-report questionnaires and most are derived from a national pool of various disciplines, including psychiatrists, psychologists, social workers and/or clergy. Since these studies rely on the willingness of therapists to report on their own behavior, it is likely that the results underrepresent the true prevalence rate.

Studies of British psychologists’ self-reported prevalence reveal data similar to the studies in the United States. In all prevalence studies, male practitioners account for over 75% of the incidence. Interestingly, female practitioners account for a relatively low percentage of the prevalence yet engage in sexual boundary violations mostly with female patients. So, males contribute about 9% to the prevalence, while females account for about 3–4%. The overwhelming majority of victims are female.

NT: What are some of the early indicators or warning signs of the increased potential for sexual boundary transgression by a therapist?

AC: The therapist is usually mid-career, isolated in his practice and is treating a difficult patient in a highly stressful time in his life. So there are situational factors that present the immediate context where the vulnerable therapist may have difficulty coping. The behavioral warning signs have to do with an attitude toward a patient where special accommodations are being offered (late appointments, double sessions, therapy outside the office, touching (hugging) the patient, etc). These are usually rationalized as therapeutic but are part of the so-called slippery slope. Once this is occurring, however, it may already be too late.

NT: Is there any evidence that there is a particular personality disposition, psychopathology, theoretical orientation or other identifying feature of therapists who violate sexual boundaries with their clients? Or are there other variables that increase the risk of such violations, such as the nature of the work that the therapist does (eg, couple therapy)?

AC: Most importantly, we must identify whether or not we have the vulnerabilities associated with what brought us to the profession in the first place.

Eight risk factors have been identified, including:

  • longstanding narcissistic vulnerability;
  • grandiose (covert) rescue fantasies;
  • intolerance of negative transference;
  • childhood history of emotional deprivation and sexualization;
  • family history of covert and sanctioned boundary transgressions;
  • unresolved anger toward authority figures;
  • restricted awareness of fantasy (especially hostile/aggressive), and
  • transformation of countertransference hate to countertransference love.

There is a chapter in my book that elaborates on all of these factors and another chapter that presents a self-administered questionnaire, designed to determine whether a therapist has these vulnerabilities. Many of us do, however we’re not aware of having certain fault-lines in our development. This measure can be used for periodic risk assessment throughout a professional’s career.

Knowledge of the ethical code has not been found to be preventative. It appears that intensive, long-term psychotherapy has more potential for burn-out, however psychodynamic clinicians have a slightly lower prevalence. This is probably due to the fact that they have better training and awareness of transference dynamics and have been in their own treatments as well. But they are far from immune.

The important issues are not the type of work but how a therapist carries it out and whether or not self-care is an integral part of their professional life. One example I like to use is that you wouldn’t go to a dentist who did not sterilize or otherwise take care of his instruments; in our profession, our emotional well-being is our instrument and we need to nurture ourselves in our personal lives before we are ready to help others. And this has to be done in an ongoing way throughout our lives.

NT: The history of therapy is peppered with stories of at least somewhat inappropriate boundary transgressions of a sexual nature by a number of leading therapists and thinkers in the field, not least of which are Sandor Ferenczi, Carl Jung, and Sigmund Freud. Do you think it can ever be the case that sexual relationships between therapist and client can ever be a part of the healing process or, at the very least, a non-destructive part of the therapy?

AC: I know of a few cases where the patients have stated that their sexual involvement with their therapist was helpful to them (or at least was not harmful). These are few and far between, however, and it’s not clear to what extent they are rationalizing, minimizing, or what might have been the extent of help they might have gotten without the sexual involvement (probably much more). There are also well known cases of patients who have married their analysts. But the great majority of patients find it harmful and the sticking point in any analysis of the problem is the power imbalance inherent in the therapeutic matrix.

In my experience, even when patients say they want to be sexually involved with me, there are other issues at play that are revealed if you don’t get involved—these would be neglected and great opportunities are lost with sexual involvement. Also, it can’t be denied that sexual involvement (or other kinds of personal involvement) engender and solidify a dependency on the therapist that then is non-negotiable and harmful for the patient.

NT: Are you able to shed some light on some of the more common dynamics that underlie a therapist’s breach of such boundaries. In other words, what is happening on a dynamic level that allows the therapist to fall into a sexual relationship with a client?

AC: The structure of the therapy situation is a template that replicates several of the familial dynamics in the vulnerable therapist (outlined above). The therapeutic context is essentially a depriving situation for the therapist in that it is asymmetric. The patient is the recipient of the attention paid and needs to be met. In contrast, it is the therapist’s responsibility to put his/her needs aside for most of the hours in the day.

At the same time, the therapy situation may be overstimulating to the therapist in that the content of many therapy hours can involve intensely sexualized material. Thus, the therapy situation itself replicates the early childhood experience of these therapists in that it is simultaneously depriving and sexually overstimulating. It is also a context where it is overtly forbidden for the therapist to gain gratification of his/ her wishes, paralleling the prohibitive atmosphere in these therapists’ childhood experience.

The critical moments in a psychodynamic therapy that hold the greatest potential for change revolve around phases of the therapy where the patient is expressing dissatisfaction with and criticism of the therapy and/or the therapist himself. Because of the therapist’s narcissistic fragility, he/she may be moved to transform the nature of the therapeutic process at this phase.

Rather than tolerate and continue to explore the patient’s dissatisfactions, the therapist becomes increasingly anxious and desperate, relying on sexualization to transform the way in which the patient is responding to him/her. Thus, the seduction occurs when the therapist believes that the therapy is at an impasse.

In this way, the process shifts from one of enormous frustration and challenge to one of seduction and sexual gratification. One therapist revealingly said, “I was reaching the end of my rope. I didn’t know how to help her… I knew how to seduce her, so that’s what I did.”

NT: What are the key challenges to the therapist transgressor in his or her rehabilitation following a sexual boundary transgression and how successful and lasting is such rehabilitation in your estimation?

First and foremost, the transgressor needs to appreciate the transgression as an egregious violation of the professional ethical code, he/she must have genuine remorse (including a sense of caring for the harm that was wrought on the patient), and he/she must be willing to take responsibility for the transgression entirely. Rehabilitation programs are arduous, begin and end with comprehensive evaluations by independent consultants who also perform a monitoring function, and involve much soul searching on the part of the transgressor. The programs usually span 2–3 years. At a minimum, there is an intensive psychotherapy component, psychoeducation, and supervision (if the transgressor is allowed to continue to practice).

Outcome research is just beginning to address the adequacy and efficacy of rehabilitation programs of transgressing therapists. I personally have conducted an informal survey on 20 cases of therapists and clergy who have completed a course in rehabilitation. Whenever possible, the follow-up data was gathered from the overseeing professional agency rather than the transgressor him or herself.

For example, in the cases of clergy transgressors, the presiding Bishop in the transgressor’s diocese was contacted and interviewed by telephone. In the cases of therapist transgressors, the licensing boards, supervisors and/or the transgressor him or herself was contacted. In a total of 20 cases, there were no reports of recidivism, nor were there any reports of concern for the professional’s conduct in general.

It is through these experiences that I have come to believe in the viability and ethical obligation of rehabilitation for the one-time transgressors. I would venture to say, as well, that with many, if not most of the rehabilitated transgressors, I come to trust their judgment and ability to maintain the highest ethical standards moreso than average practitioners, due to their experience and transformation in the rehabilitation program.

Upon close inspection, it is compelling to perceive the extent to which they have reflected upon the complexities of boundary maintenance, introspected and worked through their vulnerabilities (to a greater extent than most of us), and have enhanced their familiarity with the nuances of boundaries.

This article was originally published in New Therapist Magazine, September/October 2010

Photo courtesy of _HAAF_ on flickr

 

Collapsing into Sexuality: The Dynamics of Sexual Boundary Transgressions by Therapists

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APA Reference
Celenza,, A. (2015). Collapsing into Sexuality: The Dynamics of Sexual Boundary Transgressions by Therapists. Psych Central. Retrieved on December 18, 2018, from https://pro.psychcentral.com/collapsing-into-sexuality-the-dynamics-of-sexual-boundary-transgressions-by-therapists/

 

Scientifically Reviewed
Last updated: 3 Mar 2015
Last reviewed: By John M. Grohol, Psy.D. on 3 Mar 2015
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