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Reduce sexual boundary crossings

January 25, 2017
by Michael Shelton
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Sexual contact between clinicians and patients is a strikingly common occurrence, and two reviews indicate the extent of the issue. First, a 2007 literature review determined that between 22 and 26% of patients reported to their new practitioner that they had been sexually involved with a previous clinician, and between 38 and 52% of health professionals reported knowing of colleagues who had been sexually involved with patients.1 A second review determined that between 7 and 12% of professionals in the mental health field engage in erotic contact with clients.2 These figures are surely underestimates, since prevalence studies rely on anonymous self-reporting of offending clinicians, clients themselves, other staff members who know of an incident, or the accounts of clinicians dealing with a new client who had experienced past sexual boundary violations.

Why do staff members, many of whom seem to be otherwise outstanding and often invaluable employees, risk catastrophic consequences via engagement in sexual boundary crossings? Potential repercussions include loss of licensure or certification, expulsion from professional associations, loss of employment, loss of colleagues, the ending of marriages, legal action, financial repercussions, and, in some states, probation or imprisonment. While it would be comforting to conclude that these professionals are characterologically disturbed, the research is very clear and finds a far more worrisome conclusion: Risk is based on an ever-changing conflux of clinician characteristics, client characteristics, the nature of the therapeutic relationship in general, an agency’s milieu, and supervisory relations. A clinician who is at low risk today might be at much higher risk several months from now. Still, staff members of all disciplines minimize or outright deny this risk.

Treatment organizations also are in denial, as evident from continued use of preventative practices that are not working as they are commonly implemented. These include trainings, statements about this behavior in workplace rules and regulations, clinical supervision, and an overriding belief that knowledge of the ethical requirements of one’s discipline will serve as a deterrent. In short, the methods in use today will not significantly affect the prevalence of erotic boundary crossings between a staff member and a patient.

Understanding the process

The field of sex offender (SO) treatment is indebted to the behavioral health field; many of the latter’s models were the original building blocks of SO treatment (such as the concept of relapse prevention planning). However, as the SO field has evolved, the behavioral health field has been loath to consider sex offender treatment theories, models and practices, many of which help us understand professional boundary crossings.

Some principles used in SO treatment that are applicable to the behavioral health field in general include:

  • Typologies. The SO field continues to develop typologies for offenders to guide assessment of risk and clinical intervention, and efforts have been undertaken to elucidate subtypes of clinicians who engage in erotic boundary crossings. In an early example, Schoener and Gonsiorek identified six subtypes of transgressing professionals, ranging from the uninformed and naïve type to those with sociopathic or narcissistic characteristics.3 At present, a general typology accepted in the field contrasts one-time clinical boundary crossers, who often seek help and are genuinely remorseful, with repeat (also called predatory) clinical transgressors who have engaged in the behavior repeatedly, have little remorse, and have little likelihood of rehabilitation. Finally, it is well known that the overwhelming majority of such clinicians are men, and Celenza determined that the most common transgressor is a middle-aged male therapist in private practice who engages in sexual contact with one female patient.2

  • Beliefs. Sex offenders have underlying belief systems shaped by their upbringing that influence their behavior, particularly beliefs about gender, power and sex. Integral to SO treatment is the recognition of such beliefs and an acknowledgement of their impact on sexual behaviors. Similarly, clinicians begin their work with behavioral health agencies possessing many explicit and implicit beliefs about these same topics in addition to others that have immediate clinical salience. Examples include beliefs about physical touch, personal disclosure, flirtation during sessions, and, even more controversial, use of fantasies of a client for personal sexual gratification.

  • The offense process. One of the precepts of SO treatment is that a sex offense does not “just happen.” There is a series of intervening steps leading up to an offense, and interventions can be specifically targeted for each step. There have been attempts to formulate a similar process model for professional boundary violations. Martin and colleagues interviewed professionals who had become sexually attracted to clients, which led to the formation of a process model applicable to clinicians.4 Their five-step model entails acknowledging sexual attraction to a client and ultimately progressing to the formulation of methods to use the situation therapeutically for the client’s benefit.