Rehabilitation of Sexual Boundary Transgressors

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. Definition 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. Common characteristics 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 One objection involves the unwillingness to forgive such an egregious violation of trust. Whether the transgressor is capable of being rehabilitated is not the central point to this argument; the underlying assumption is that mental health practitioners are a privileged group (officially privileged by virtue of licensure and other types of certification) and thereby must be held to a higher standard. The argument is that if a practitioner behaves in a way that demonstrates an inability to uphold the highest values of the profession, these privileges should be permanently revoked. But what if the problem is more complex and rests on a universal vulnerability to which we all have the potential to succumb? Is it fair or even reasonable to hold such standards in a way that professes an illusory fortification against transgressing boundaries? I think not, given that we now have many examples of highly trusted and talented colleagues (not of the psychopathic ilk, it is important to stress) who have been unable to maintain their highest ethical standards at a certain time in their life, with a certain patient, and under certain circumstances. To hold that one is and always will be immune to sexual boundary transgression when ours is a most intimate, emotional, and involving form of work is imprudent at best and at worst, cavalier. How do any of us know what stresses, needs, or tragedies might await us in the coming decades? One transgressor with whom I worked had a recurrence of a potentially fatal illness during a time of marital discord. His transgression followed an illustrious career as a highly trusted teacher and senior therapist with years of experience. Sadly, his case is not uncommon. A more difficult objection points out that many (if not most) transgressors have already had psychotherapeutic treatment. In the cases of psychodynamic or psychoanalytically trained therapists, treatments have been both intensive and long-term. Studies do show a lower prevalence of sexual boundary trangression among clinicians representing these orientations; however, the rate is by no means low. Is the vulnerability to sexual boundary transgressions impervious to change and does this not argue for the lack of rehabilitation potential in us all? On the contrary, the persistence of sexual boundary transgressions, even among the previously treated, underscores our universal vulnerability.8 The most compelling explanation invokes a developmental understanding of our ethical responsibilities in which the life-stage circumstances and mental state of the practitioner are taken into account across the span of his professional life (Behnke S, personal communication; 2007). Ethical standards and our ability to practice within them are capacities that exist in a timeframe and within a mental state. The universal vulnerability to sexual boundary transgressions is difficult to imagine only if we view it from within a current, stable frame of mind. A spouse may not be able to imagine infidelity in the early years of marriage nor a priest a loss of faith at ordination. As life deals its blows, we grow and change with it. Midlife pre-sents challenges that those before it or beyond it may not appreciate. At the same time, it is not sufficient to refer to the midlife crisis as the total explanation for these unethical acts because most of us make it through this life stage without professional self-destruction. Assessing rehabilitation potential Through my professional involvement with more than 75 cases of sexual boundary transgressions, I have come to believe in the viability of and the ethical obligation for the rehabilitation of one-time transgressors. While there were a minority of cases in which rehabilitation was not viable and was not undertaken, in the majority of cases, my involvement represented some aspect of a comprehensive rehabilitation plan. In most of the cases in which rehabilitation was recommended and carried out, my role was to perform the initial and follow-up evaluations. Primarily, the initial question revolved around whether rehabilitation was indicated and, if so, how to construct a comprehensive treatment program. The main question at follow-up was to assess the adequacy and thoroughness of the rehabilitation with attendant questions of readiness to return to practice. I would venture to say, as well, that with many, if not most of the rehabilitated transgressors, I have come to trust their judgment and ability to maintain the highest ethical standards more than I do average practitioners because of the experience and transformation in the rehabilitation program. It is compelling to perceive the extent to which these therapists have reflected on the complexities of boundary maintenance, have been introspective, have worked through their vulnerabilities (to a greater extent than most of us), and have enhanced their familiarity with the nuances of boundary management and self-care. Independent assessments aimed at evaluating rehabilitation potential of transgressors have been carried out for decades by a small group of practitioners specializing in the area of sexual boundary transgression.1,3,4 Usually, the evaluation is requested after the case has been adjudicated by an overseeing professional agency, such as a licensing board, a professional organization, or even after civil litigation. In most cases, the evaluator will be hired by the overseeing agency. It is crucial that the evaluation be performed in an independent manner, ie, the evaluator is not partial to the outcome and does not have conflicts of interest or a previous relationship with the transgressor. The evaluation usually takes about 20 hours, with 5 to 6 hours of personal interviewing, psychological testing (especially personality testing), and gathering of collateral information. All documentation is reviewed, the nature and scope of the transgressor's practice is determined, and the transgressor's family situation is explored. Each evaluation is individually tailored. The victim/survivor may also be interviewed because the degree of consistency between the transgressor's and the patient's narrative is an important factor in assessing the transgressor's credibility. In all cases, a thorough exploration of the transgressor's point of view is emphasized, including his attitudes, beliefs, and understanding of how and why the transgression occurred. The emphasis on the transgressor's experience is designed to thoroughly evaluate his functioning at the time of the transgression, the rationalizations that were used, the limitations of his understanding of the nuances of boundary maintenance, and the specific limitations in his ability to handle the treatment at the time. All of these issues bear directly on the foci of the rehabilitation plan should it be recommended. The first question to address is whether the transgressor has the crucial character traits and attitudes that indicate a good prognosis.1 I have constructed a 20-item checklist to use in the interview that delineates these characteristics. In addition, the Boundary Violations Vulnerability Index is designed to assess the presence or absence of several precursors of vulnerability to sexual boundary violations.8 This tool may also be used by practitioners for self-monitoring to identify risk factors before any steps on the slippery slope are taken. Rehabilitation programs Rehabilitation programs should be individually tailored, because not all transgressors have the same needs, and not all components will be necessary to each circumstance. It is important that only relevant safeguards are applied. Most rehabilitation programs last 2 to 3 years and involve some or all of the following: • Assignment of an independent rehabilitation coordinator to monitor the overall program and communicate among all the participants. • Individual psychotherapy or psychoanalysis to address the specific problems identified in the evaluation. • Couples therapy is almost always indicated to address neglected marital problems, as well as the trauma of the complaint process itself. • Supervision performed by independent practitioners who have expertise in boundary issues; the supervisor must be thoroughly informed of the details of the misconduct and must be willing to report to the overseeing agency regarding progress. • Practice limitations for the rehabilitation period, the most common of which is a limitation on independent practice. • Psychoeducation on ethics and boundary management. • Mediation may be indicated to address lingering injuries from the transgression itself and to give the transgressor the opportunity to acknowledge wrongdoing. Efficacy of rehabilitation Outcome research is just beginning to address the adequacy and efficacy of rehabilitation programs for therapists who transgress. I have conducted an informal survey on 32 cases involving therapists and clergy for whom rehabilitation had been recommended. In each of these cases, the rehabilitation program was either under way or had been completed. At the time of the study, most cases were more than 4 years postrehabilitation (n = 20) with a range of 1 to 10 years for all of the cases. Whenever possible, the follow-up data were gathered from the original overseeing professional agency rather than from the transgressor. For example, in the cases of clergy transgressors, the presiding Bishop in the transgressor's diocese reported on outcome and recidivism. In the cases of therapist transgressors, the licensing board, supervisor, and/or the transgressor were contacted. In a total of 32 cases, 3 transgressors had retired, one was deceased, and 5 were not included because of incomplete data. In the remaining viable cases (n = 23), no reports of recidivism were received nor were there any reports of concern for the professional's conduct in general. In 11 cases where I was directly involved in the rehabilitation program in an ongoing way (as therapist or supervisor), the rehabilitations were assessed by an outside evaluator as successful. In addition, by virtue of their involvement with the rehabilitation program, I gained a greater trust in these therapists than I have for the average therapist. Conclusion There is no problem that better underscores our need for self-care throughout our professional lifespan than the problem of sexual boundary transgressions. Mental health practitioners of all disciplines tend toward ministering to others as a character trait and way of life. It is incumbent upon us to monitor our own needs in a way that takes into account the developmen- tal challenges we are likely to face throughout our professional careers. References: References 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.