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Sexual boundary transgressions by therapists
By Andrea Celenza
Andrea 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 identity after such breaches.
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?
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 ACelenza@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. See the next response for more important risk factors (related to the therapist’s development and personality) and a measure to help prevent transgressions.
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.