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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 the extent of help they might have gotten without the 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.

 

 

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