In my work in sexual boundary violations, now spanning almost 25 years, there are 2 things that have not changed. One is the prevalence or the frequency of at least one type of sexual boundary transgression. The second is our inability or unwillingness to comprehend the nature and complexity of the problem. The latter intransigence prevents a third factor from emerging, one that I hope to further promote in this article—that is, openness to the viability of rehabilitation.
This curious lag in understanding is promoted by a pervasive misunderstanding that blocks the integration of new knowledge. The misunderstanding is the tendency to associate transgressors of sexual boundary violations with the most egregious, distasteful, and shame-inducing examples that are actually rare but have caught the media's attention. There is also a retrospective revisionism that occurs when a previously esteemed and trusted senior colleague commits a sexual boundary transgression. Then all that had been done before by the formerly trusted colleague (now transgressor) is tainted and viewed through smoke-clouded lenses.
This obfuscation actively stands in the way of developing an informed, reasonable, and compassionate understanding of the problem. To put it simply, the idea that all transgressors are psychopathic predators, a type that indeed is not amenable to rehabilitation, rules out rehabilitation for all, even those who would benefit from intervention and who represent the most prevalent type. This resistance no doubt consists of, at least in part, a defensive disowning of the vulnerability to sexual boundary violations in all of us.1 We would do well to heed the words of Harry Stack Sullivan, "We are all much more human than otherwise"2 and apply this piece of wisdom to our approach.
Sexual boundary violations are any kind of physical contact that occurs in the context of a therapeutic relationship for the purpose of erotic pleasure. The therapeutic context (and this applies to psychopharmacological or so-called medical back-up relationships) contains a power imbalance inherent in the structure of the relationship. This imbalance derives from many sources but revolves primarily around the unequal distribution of attention paid to the client, patient, or student as compared with the therapist, analyst, teacher, or member of the clergy. Furthermore, the patient comes to therapy seeking help, guidance, support, and self-knowledge, and he or she is usually in a state of emotional disequilibrium, distress, or need. Finally, the therapy process encourages unresolved, transference-based relationships in which the patient will begin to experience the therapist as an important and conflictual figure from the past. Usually, this takes the form of an intense yet unresolved mode of relating derived from early childhood, most often with a parent.
It is through the structure of the therapeutic setting and the imbalance inherent in this structure that the patient is rendered particularly vulnerable to exploitation, especially of a sexual nature. This structure renders the patient's consent moot, even if the patient desires erotic contact with the therapist. Indeed, it is fair to say that the patient is likely to desire erotic contact with the therapist because sexualization and erotic longing naturally occur when transference-based relationships of many types are stimulated. It is the therapist's responsibility, therefore, to maintain the clarity of roles in the face of these inherent and developing pressures.
The one-time offender (usually narcissistically needy, lovesick, or from the masochistic-surrender category) is the most prevalent type of sexual boundary transgressor.1,3,4 The most common scenario involves a heterosexual male therapist who becomes sexually involved with a patient. (For ease of discussion, I will refer to the transgressor as "he" or "the therapist" and the patient as "she" or "the patient" because this is the most frequent gender pairing.)
In addition, the therapist is usually in mid-career, is isolated in his practice, and is treating a difficult patient during a highly stressful time in his life. The relationship is usually intense, may last for several years, and the couple may feel that they have found "true love," at least initially. Sometimes the therapy relationship is terminated while the sexual relationship continues. If the relationship is brought to an end by the therapist, this is the time when an ethical complaint is most likely to be filed by the patient.
There are several common characteristics related to the therapist's personality, life circumstance, past history, and the transference/countertransference dynamics of a particular therapist-patient pair.5-7Table 1 (Table restricted. Please see print version for content) presents the precursors to sexual boundary violations.5,8 While certain precursors may be long-standing, most researchers have found these therapists capable of conducting competent and ethical treatment for most of their careers.4,8 For these types of transgressors, the greatest risk involves a particular transference/ countertransference (mis)fit at a highly stressful time of their lives.
A typical situation involves a middle-aged, male therapist who is moderately depressed, dissatisfied with his marriage, and isolated in his practice. He is an only child with at least one highly critical parent, and the other parent is usually perceived as uninvolved. The family context was unloving and emotionally depriving, yet also seductive in an unacknowledged way. Perhaps one parent was unfaithful or committed financial misdeeds. The child (now transgressor) grew up somewhat inhibited with high standards for himself but is unable to acknowledge his underlying disappointment, anger, and unmet needs.
The structure of the therapy situation is a template that replicates several of these familial dynamics. The therapeutic context is emotionally depriving (for the therapist) yet also overstimulating 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 in which it is overtly forbidden for the therapist to gain gratification of his wishes, paralleling the prohibitive atmosphere of his childhood experience.
Sexual boundary transgressions generally do not occur in situations where the therapist and patient have overt appeal for each other from the start. It is usually in the context of a stalemated, difficult treatment, with the seduction occurring when the therapist believes 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."
Rehabilitation: for and against If we look closely at the common characteristics of the one-time transgressor (Table 2), we recognize that these are the characteristics that frequently prompt individuals to seek psychotherapeutic help. In addition, many of these characteristics are neurotic-level problems (such as genuine remorse), and others are hallmarks of a good prognosis for treatment (such as the ability to take responsibility for one's actions). Therefore, it is puzzling that rehabilitation for transgressors is not generally accepted; this is ironic when we remember that our entire profession is based on the belief that people can change through our interventions.1
1. Celenza A, Gabbard GO. Analysts who commit sexual boundary violations: a lost cause? J Am Psychoanal Assoc. 2003;51:617-636.
2. Sullivan HS, Perry HS. The Interpersonal Theory of Psychiatry. New York: Norton; 1953.
3. Schoener GR, Milgrom JH, Gonsiorek JC, et al, eds. Psychotherapists' Sexual Involvement With Clients: Intervention and Prevention. Minneapolis: Walk-In Counseling Center; 1989.
4. Gabbard GO, Lester EP. Institutional responses. In: Gabbard GO, Lester EP, eds. Boundaries and Boundary Violations in Psychoanalysis. New York: BasicBooks; 1998:175-195.
5. Celenza A. Precursors to therapist sexual boundary violations: preliminary findings. Psychoan Psychol. 1998;15:378-395.
6. Twemlow SW, Gabbard GO. The lovesick therapist. In: Gabbard GO, ed. Sexual Exploitation in Professional Relationships. Washington, DC: American Psychiatric Press; 1989.
7. Gonsiorek J, Schoener GR. Assessment and evaluation of therapists who sexually exploit clients. Prof Pract Psychol. 1987;8:79-93.
8. Celenza A. Sexual Boundary Violations: Therapeutic, Supervisory, and Academic Contexts. New York: Jason Aronson; 2007.