Sexual Attraction in Therapy Managing Feelings of Desire in

Clinical Practice, 1st Edition

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Sexual Attraction
in Therapy
Managing Feelings of Desire
in Clinical Practice

Michael Shelton
First published 2020
by Routledge
52 Vanderbilt Avenue, New York, NY 10017
and by Routledge
2 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN
Routledge is an imprint of the Taylor & Francis Group, an informa
business
© 2020 Taylor & Francis
The right of Michael Shelton to be identified as author of this
work has been asserted by him in accordance with sections 77
and 78 of the Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this book may be reprinted
or reproduced or utilized in any form or by any electronic,
mechanical, or other means, now known or hereafter invented,
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trademarks or registered trademarks, and are used only for
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Library of Congress Cataloging-in-Publication Data
A catalog record for this title has been requested

ISBN: 978-0-367-20593-5 (hbk)

ISBN: 978-0-367-20596-6 (pbk)
ISBN: 978-0-429-26245-6 (ebk)

Typeset in Avenir and Dante

by Swales & Willis, Exeter, Devon, UK
For Donald and Janice
Contents

Introduction: An Overview of the Problem 1

1 A Roadmap for Navigating the Risks of Therapy 14
2 The Boundary Violation Cycle 26
3 Risk and Vulnerability Factors 40
4 Managing Fantasies 54
5 Choosing: Talking Ourselves into (and out of)
Sexual Predicaments 70
6 Using Clients to Meet Unfulfilled Needs 87
7 Non-Sexual Boundary Crossings 99
8 Violations and Post-Violation Considerations 115
9 Education, Training, and Supervision 124
10 Organizational Change 139
11 Removal or Rehabilitation 157
Conclusion: We’re All in This Together 164

Index167
Introduction
An Overview of the Problem

Every person employed in the mental health field, whether as a counselor,

therapist, psychologist, or social worker, knows that it is never acceptable for
a professional to engage in a sexual or romantic relationship with a patient. As
part of one’s education, training, supervision, and licensure preparation the
message that sexual and romantic activity between a practitioner and a patient
is censurable and harmful is clearly and repeatedly emphasized. Still, there is
a long history of sexual boundary violations; consider some of the pioneers in
talk therapy who became romantically involved with clients: Carl Jung, Erich
Fromm, Frieda Fromm-Reichmann, Harry Stack Sullivan, and Karen Horney
(Alpert & Steinberg, 2017; Blechner, 2014). At the time these incidents were
justified as instances of transference and countertransference gone awry or
even as true love, and the most severe outcome was professional censure.
It was not until the late 1960s that malpractice cases arising from boundary
violations began to accrue, and two hallmark cases galvanized the field to
action. Zipkin v Freeman (1968) determined the defendant had manipulated his
patient to become his mistress and leave her husband. More infamous, Roy
v Hartogs (1975) found a provider utilized sexual intercourse as a treatment
technique for the patient’s presenting problems, leading to an exacerbation of
her mental health concerns.
In the wake of this rising awareness of sexual boundary violations efforts to
elucidate the actual extent of the problem were undertaken. As one example,
Pope, Levenson, and Schover (1979) found that 12% of male and 3% of female
psychotherapists reported sexual contact with their clients. A decade later,
Simon (1989), a leader on the topic, estimated that 7%–10% of mental health
professionals sexually exploit their patients; however, he stated these figures
were likely low due to underreporting. The actual incidence, he proposed
2  
Introduction: An Overview of the Problem

could be as high as 25%. Professional associations, state licensing boards, and

insurers, taking note of these alarming figures and costly financial settlements
to victims, began to promulgate official directives banning this behavior.

Collecting Data

Our understanding of the extent of sexual boundary violations in clinical prac-

tice comes about by three methods. First, clinician self-reporting, typically
through use of anonymous surveys. Carr, Robinson, Stewart, and Kussin
(1991), in an early review of the literature, determined that 7.1% to 10.9% of
male therapists and 1.9% to 3.5% of female therapists admitted to engaging
in intimate contact with patients. Halter, Brown, and Stone (2007), in their
exhaustive review of available literature, remind us that self-reporting likely
leads us to underestimate the true prevalence of sexual boundary violations.
They concluded that while self-reporting over the last two decades indicates
a decline in the incidence of the behavior this may be the result of clinicians
becoming more secretive due to fear of sanctions.
A second method of determining the extent of sexual boundary violations
is patient disclosure of a past sexual boundary violation to a new clinician as
well as clinical awareness of transgressing colleagues. Aforementioned ­Halter
et al. (2007) determined between 22% and 26% of patients report having
been sexually involved with a previous therapist to another practitioner and
between 38% and 52% of health professionals report knowing of colleagues
who were sexually involved with patients. This source of data likely too
underestimates the extent of sexual boundary violations. Pope (1994) deter-
mined that many clinicians simply do not believe clients when they disclose
violations by former professionals. Others are so uncomfortable, confused,
or overwhelmed by a client’s disclosure that they simply do not act on it.
Gartrell, Herman, Olarte, Feldstein, and Localio (1987), for example, sur-
veyed 1423 psychiatrists. 65% reported treating patients who had been sex-
ually involved with previous therapists but only 8% reported these incidents.
Finally, we can look at official complaints made to state licensing boards
and/or professional associations. In two early studies, occurring at a time
when far fewer states had licensing boards, Herlihy, Healy, Cook, and Hudson
(1987) and a follow-up study 5 years later, Neukrug, Healy, and Herlihy (1992),
found that the two most common complaints to licensing boards were prac-
ticing without a license or other inaccurate representation of qualifications,
and having a sexual relationship with a client. The latter study determined that
20% of complaints made to the board were due to the sexual relationships.
 Introduction: An Overview of the Problem 3

Germaine (1997) surveyed state certification boards for addiction counselors

and ascertained that the most common complaint involved a sexual relation-
ship with a current client, which comprised 16% of complaints. Neukrug, Mil-
liken, and Walden (2001) surveyed state credentialing boards and found the
behavior most often leading to disciplinary action was dual relationships. The
authors determined 7% of these dual relationships were of a sexual nature.
Boland-Prom, Johnson, and Gunaganti (2015) conducted a study of the types
of ethical complaints that resulted in disciplinary actions in the field of social
work and found 9.5% were related to sexual relationships. Wilkinson, Smith,
and Wimberly (2019), found 9% of ethical complaints to state licensing boards
arose from sexual relationships. Finally, Phelan (2007) examined ethical vio-
lations leading to expulsion from the major counseling, social work, and psy-
chology associations and found the most common reason for expulsion fell
under the category of dual relationships, particularly those of a sexual nature.
Liability insurance providers too track violations since they must pay set-
tlement claims for incidents. In a very recent report, CNA, a leading insurance
provider for mental health counselors, determined that engaging in a sexual
relationship with a client or a client’s family members accounted for 36.4%
of all closed claims between the years of 2013 and 2017. The costs associated
with these cases are staggering, at an average of $113,642 (Healthcare Provid-
ers Service Organization & CNA, 2019).
Using all of the above sources of data, Celenza (2007) estimated the inci-
dence rate of professional sexual boundary violations between professionals
in the mental health field and their clients is between 7% and 12%. She also
determined that males are overrepresented in these violations and account
for 7%–9% while females account for 2%–3%.

Professional Directives

For decades, numerous entities have acknowledged the problem of sexual

boundary violations and collectively urged the creation of safeguards against
the behavior. State licensing boards are an example. Each state in the United
States has its own licensing board that oversees activity in its respective juris-
diction. My state of Pennsylvania, as part of the licensure process, requires
petitioners to read and sign an ethical statement, which includes the directive,
“Sexual intimacies between a licensed professional counselor and a current
client/patient, or an immediate family member of a current client/patient,
are prohibited” (State Board of Social Workers, Marriage and Family Thera-
pists and Professional Counselors, n.d.).
4  
Introduction: An Overview of the Problem

Professional associations too dictate that sexual and romantic relationships

with clients are unethical. Consider the official pronouncements by the larg-
est professional associations in the field:

• The American Counseling Association – Sexual and/or romantic coun-

selor – client interactions or relationships with current clients, their
romantic partners, or their family members are prohibited. This prohibi-
tion applies to both in-person and electronic interactions or relationships
(American Counseling Association, 2014).
• The National Association of Social Workers – Social workers should
under no circumstances engage in sexual activities, inappropriate sexual
communications through the use of technology or in person, or sexual
contact with current clients, whether such contact is consensual or forced
(National Association of Social Workers, 2017).
• The American Psychological Association – Psychologists do not engage
in sexual intimacies with current therapy clients/patients (The American
Psychological Association, 2017).
• The American Association of Sexuality Educators, Counselors and Ther-
apists – The Certified member practicing education, counseling or ther-
apy shall not engage, attempt to engage or offer to engage a potential,
current, or former consumer in sexual behavior whether the consumer
consents to such behavior or not (The American Association of Sexuality
Educators, Counselors and Therapists, 2014).
• The Association for Addiction Professionals – Addiction Professionals
shall not engage in any form of sexual or romantic relationship with any
current or former client, nor accept as a client anyone with whom they
have engaged in a romantic, sexual, social, or familial relationship. This
prohibition includes in-person and electronic interactions and/or rela-
tionships (Association for Addiction Professionals, 2016).
• The American Association for Marriage and Family Therapy – Sexual
intimacy with current clients or with known members of the client’s fam-
ily system is prohibited (American Association for Marriage and Family
Therapy, 2015).

Additionally, an increasing number of states have criminalized sexual activ-

ity between mental health professionals and patients. California law, as
one example, makes it a crime for a therapist to have sexual contact with
a patient. Finally, employers have policies that inform employees that
romantic and sexual relationships with clients are prohibited and grounds
for termination.
 Introduction: An Overview of the Problem 5

As described above, insurance providers, state licensing boards, profes-

sional associations, workplaces, and increasingly the criminal justice sys-
tem condemn sexual boundary violations. Still, these violations continue to
occur.

Damaging Consequences

If the existence of professional directives and ethical statements is not suffi-

cient to deter engagement in a sexual boundary violation, knowledge and
even fear of consequences should theoretically be adequate discourage-
ment. Once a sexual boundary violation occurs, the involved clinician must
engage in offensive machinations to avoid detection, which in themselves
are exhausting. For example, a professional must manage the reactions of
the client in order to prevent the latter disclosing the incident; this often
includes conspiring with the client to maintain secrecy. Additionally, there
is a continued need to keep others from learning about the violation, which
requires manipulation of the environment as well as friends, colleagues, and
family. These measures complicate the already overwhelming psychologi-
cal repercussions that frequently follow sexual boundary violations, such as
guilt, remorse, and fear.
If and when a sexual violation is made public catastrophic consequences
befall professionals engaging in the behavior, including:

• loss of career;
• loss of licensure;
• loss of family, friends, and professional colleagues;
• expulsion from professional organizations;
• financial penalties; and
• civil and criminal lawsuits.

Sexual boundary violations impact not only the involved clinician but also the
organization in which they practice. From an organizational perspective, the
unearthing of sexual contact between a staff member and a client leads not
only to lawsuits, police and governmental investigations, bad press, financial
costs, and the dismissal of once-valued staff members but also to institutional
trauma. Pervasive denial, helplessness, anger, and guilt form a toxic environ-
ment infiltrating the lives of all employees, which leaks into the treatment
milieu. Brown (1997) compellingly argues that in the aftermath of a sexual
boundary violation, in which the sole focus is on the victim, the reactions of
6  
Introduction: An Overview of the Problem

colleagues and supervisors, often feeling betrayed and aghast, are inadvert-
ently disregarded. Too often the transgressing clinician is terminated and dis-
appears completely from their lives and staff end up coping on their own. In
sum, a sexual boundary violation leads to an institutional crisis and can have
long-term traumatic effects (Honig & Barron, 2013).
Finally (the topic amassing the most research), sexual boundary violations
do considerable and often lasting damage to clients. Whether the violation is
a singular instance or evolves into an ongoing sexual and/or romantic rela-
tionship, frequent sequelae are noted (Luepker, 1999; Pope, 1994; Tschan,
2014; Wohlberg, 1999) which can occur quickly or have a delayed onset:

• guilt and self-blame;

• ambivalence about seeing another professional and not trusting them-
selves to evaluate and select a subsequent provider;
• mental health disorders and symptoms, particularly posttraumatic stress
disorder, major depressive disorder, suicidality, and/or substance misuse;
• resurgence of presenting problem(s);
• disrupted relationships;
• disruptions in work or earning potential;
• sexual confusion;
• relationship difficulties; and
• boundary disturbances.

Celenza (2007), a leader in the field, concludes that the damage of bound-
ary violations does not result solely from sexual activity but rather through
betrayal of trust, demands for secrecy, reversal of roles, and the abandonment
of therapeutic aims. Tschan (2014) defines sexual boundary violations as a
“relational crime” since mental health professionals are frequently significant
attachment figures for patients; as such, a sexual boundary violation is trau-
matic. As mentioned earlier, when disclosing to a subsequent clinician many
patients are met with disbelief, the impact of the violation is minimized, and
they are held as responsible or partially responsible for the act; these responses
in themselves are re-traumatizing.
When added to the directives and ethical requirements of licensing boards,
professional associations, and workplaces, the noted consequences for clients,
organizations, and professionals themselves should ideally act as defenses
against sexual boundary violations. Still, they occur. Pope, Keith-Spiegel, and
Tabachnick (1986) concluded that reliance on sanctions and fear of conse-
quences has not proven particularly effective in stemming sexual boundary
violations.
 Introduction: An Overview of the Problem 7

Parallel Efforts at Prevention

Reducing the prevalence of inappropriate, unethical, and damaging sexual

activity is obviously not the sole purview of the mental health field, and the
recent spate of high-profile-incidents and media investigations into varied
disciplines indicates how widespread the behavior actually is. Several recent
meta-analyses and research reviews regarding sexual harassment and sexual
assault in the workplace, on college campuses, and within the military offer
the mental health treatment field guidance as how to tackle the problem.
Efforts at ending inappropriate behavior in these three domains freely borrow
from one another, and similarities are noted.
First, the workplace, the military, and universities have moved away from
the “bad apple” hypothesis, postulating that the majority of unwanted sexual
behavior in these settings is the result of a few sociopathic or highly dan-
gerous individuals. All acknowledge the need to screen for such applicants
and to remove them as quickly as possible but also admit that the problem
is far more common than the machinations of this relatively small group
could account for. In short, individuals with no seeming predisposing factors
engage in sexual behaviors antithetical to a discipline or workplace’s mission.
The mental health field in contrast continues to espouse confidence in the
false notion that the majority of sexual boundary violations are the result of a
few predatory individuals.
Second, prevention efforts require education that must be comprehensive
and ongoing. A one-time and/or brief training is rarely successful. Consider
the recommendations of Vladutiu, Martin, and Macy (2011) in their litera-
ture review of university-based sexual violence prevention program: train-
ings should focus on behavioral intent, rape awareness, rape knowledge,
rape empathy, and rape myth acceptance for both genders. A later literature
review by the Johns Hopkins Center for Injury Research and Policy (2018)
also determined the importance of a broad approach, including topics such
as rape myths, gender norms, statistics on university based sexual assaults,
communication skills, and physical resistance trainings. Regarding the United
States military, Turchik and Wilson (2010) reviewed literature and deter-
mined that changing normative views about sex and gender is necessary for
reducing risk of sexual assault. In all, a prevention program must comprehen-
sively tackle a litany of controversial and uncomfortable topics. Compare this
to the current approach in the mental health field, which does not require
mandatory training on the topic at all; it is instead interpolated into general
ethics trainings. The topic may be partitioned into a mere 10–15 minutes (or
less) out of a 3-hour ethics training.