Sexual Boundary Violations

How Do They Happen and Prevention

9:00-10:00 Sexual Boundary Violations: How do They Happen?
10:00-10:15 Rate Your Own Vulnerability:  Boundary Violations Vulnerability Index (BVVI)
10:15-10:30 Break
10:30-Noon Precursors to Sexual Boundary Violations
Noon-1:00 LUNCH
1:00-2:30 BVVI Scoring & Discussion:  Research Findings
2:30-4:00 Power Structures and Boundaries
4:00-5:00 Questions & Answers


Sexual Boundary Violations:

Therapeutic, Supervisory and Academic Contexts

Andrea Celenza, Ph.D.

This workshop would present the problem of sexual boundary violations among mental health practitioners and other relationships that contain an inherent power imbalance. Such relationships include therapist/client, supervisor/supervisee, teacher/student and clergy/parishioner. The form of the workshop would be multi-media, power point in a manner designed to encourage audience participation. I would review and incorporate findings from empirical studies on prevalence, precursors, risk factors and prevention. Most importantly, I would provide the audience with a preventive measure, based on a study of personality characteristics of transgressors. This measure is designed for clinicians to use periodically to assess personal risk. (This measure and its construction are described more fully below.)

This workshop would be relevant to the full spectrum of professionals in the psychology field as well as anyone who is in psychotherapy, including psychologists, counselors, psychotherapists, psychology professors and psychology supervisors, researchers, psychology trainees, students, and supervisees. I also think this workshop would have a wide appeal to consumers of psychotherapy, the potential victims of sexual misconduct. Though I would discuss the various issues at a high academic level, this workshop would appeal to graduate students and psychologists at every stage in their professional career. It is especially needed for those in mid- to late-career when sexual transgressions are more likely to occur.

Sexual misconduct between therapists and patients is a problem that has only recently received attention by the mental health disciplines and college/university educators.  It is recognized as unethical due to the power imbalance inherent in the structure of the therapist-patient and teacher-student dyads. It is now considered the most serious ethical violation for a therapist, psychoanalyst, clergy person and professor.

While discussing the problem of sexual misconduct is no longer taboo, evidence suggests that prevalence has not decreased nor are there programs, teaching methods, or preventative measures that adequately address the problem. I am proposing a workshop based on my work (Celenza, 2007) and other researchers in this area (e.g., Schoener et al., 1989; Gabbard and Lester, 1995) that would address this gap. Such a workshop would provide educators, trainers, and clinicians with experience to aid in setting up programs, ethics workshops, seminars, and other educative or clinical teaching projects. This workshop would provide professionals with guidance on how to understand the problem of sexual misconduct from a variety of perspectives, including precursors, risk factors, supervisory concerns, psychodynamic underpinnings, preventative methods, and rehabilitation efforts.

In the therapeutic context, the therapy process tends to encourage transference-based relationships derived from early childhood, so the patient is particularly vulnerable to exploitation. The consequences of having a sexual relationship with one’s therapist are very serious since sexual misconduct betrays the trust and sanctity of the therapeutic relationship. Once a patient has been exploited in this way, he or she is much less likely to seek help in a therapeutic context despite that he or she may suffer from depression, low self-esteem, and other effects of sexual trauma.

Prevalence studies consistently reveal an unacceptably high incidence rate (9-12%) of erotic contact between therapists and patients among mental health practitioners. All prevalence studies to date have been comprised of anonymous, self-report questionnaires derived from a national pool of various disciplines, including psychiatrists, psychologists, psychoanalysts, social workers, and clergy.  Since these studies rely on self-report, it is likely that the results under-represent the true prevalence rate. In malpractice prevention and risk management consultation, boundary issues account for a considerable portion of legal and ethical complaints and the problem of sexual misconduct between therapists and patients, in particular, is a large proportion of these cases.

In all prevalence studies, male practitioners account for over 80% 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 (Pope, Levenson, and Schover, 1979; Gartrell et al., 1986; Borys and Pope, 1989; Schoener et al., 1989). Therefore, most victim-patients of sexual boundary violations are female, whether the therapist is male or female and the patient population most likely to be harmed by sexual boundary violations is female. Schoener et al. (1989) reported 80% of their victim-patients were women who had been sexually abused by a male therapist and more than 10% of their victim-patients were women abused by a female therapist. In general, the prevalence studies report that approximately 4% of female therapists admit to having sexually exploited their patients/clients.

Despite the high prevalence and widespread concern among therapists, patients, and the public at large, the problem of sexual boundary violations is not well understood. Several misconceptions hinder therapists’ ability to recognize and address risk factors and vulnerabilities that otherwise might facilitate prevention.  Studies generally show remarkable consistency in age, gender, and practice characteristics in that the typical transgressor is a middle-aged male therapist in solo private practice who engages in a sexual dual relationship with one female patient (see, for example, Borys and Pope, 1989; Jackson and Nuttall, 2001; Lamb and Catanzaro, 1998; Pope et al., 1979). Some studies have suggested that as therapists age and gain more experience, ethical judgement falls below previously held standards (Borys and Pope, 1989; Lamb et al., 1994). These and other risk factors have been identified (Schoener et al., 1989; Gabbard, 1994; Celenza, 2007) and would be the focus of the workshop.

I am a psychologist/psychoanalyst known for my work in the area of sexual misconduct between therapists and patients. I have recently published a book (Celenza, 2007) and have written over a dozen articles on the subject of sexual boundary violations, all of which are published in highly regarded, peer-reviewed professional journals in the area of psychotherapy, ethics, and psychoanalysis. I have presented papers at local, national, and international conferences. I have also been an invited speaker to graduate training programs in psychology, inpatient and outpatient psychotherapy clinics, as well as psychoanalytic institutes across the country.

My papers have been useful to educators, trainers, and clinicians of all mental health disciplines. In addition to teaching and presenting papers, I have personally treated, evaluated, supervised and/or consulted on over seventy cases of sexual boundary violations, notably from the point of view of the transgressor. I have become known for my expertise in aiding directors of training programs at all levels and have been asked to set up procedures, evaluate cases, and consult to professional organizations, ethics bodies, and licensing boards when such cases come to light.  My work also has been used in ethics courses at both graduate and post-graduate levels in university based psychology programs.

I have been interested in developing training, educative, and preventative programs aimed at helping professionals of all mental health disciplines, including trainers, supervisors, professors, and the caregivers themselves. I have been especially interested in helping practitioners and those who oversee, supervise, and train therapists at all levels of training. Most efforts to understand the problem of sexual misconduct have been aimed primarily at supporting the victims of such exploitation and setting up educative and disciplinary guidelines to deter transgressors.

This workshop would be distinguished from others on this topic in that it would include the employment of a assessment tool and preventative measure that caregivers could use to identify levels of risk or vulnerability at different points in their career. To date, there have been no preventative measures aimed at addressing the vulnerabilities of transgressors, though such measures are sorely needed. This measure derives from a research project that I have conducted that employed eleven reliable and validated psychological measures. This is an empirically controlled, double blind study. Several of the measures successfully differentiated transgressors from non-transgressors. These measures are combined to develop a ‘Boundary Violation Vulnerability Index’ based on this research. The BVVI is designed as a preventative tool to aid therapists in training as well as those at different points in their careers in order to monitor levels of risk.

A tentative outline of the workshop is above. It is designed as a full day, seven hour workshop but can be modified to suit particular needs.

 Selected Bibliography

Borys, D.S. and Pope, K.S. (1989). Dual relationships between therapist and client: A national study of psychologists, psychiatrists, and social workers. Prof Psychol: Res and Practice. 20:283-293.

Celenza, A. (2007).  Sexual Boundary Violations: Therapeutic, Supervisory and Academic Contexts.  New York: Jason Aronson.

Gabbard, G.O. and Lester, E. (1995). Boundaries and Boundary Violations in Psychoanalysis. New York: Basic Books.

Gartrell, N, Herman J, Olarte S, Feldstein M, and Localio, R. (1986). Psychiatrist-patient sexual contact: Results of a national survey, I: Prevalence.  Am J Psychia. 143:1126-1131.

Jackson, H. and Nuttall, R.L. (2001). A relationship between childhood sexual abuse and professional sexual misconduct.Professional Psychology: Research and Practice, 32(2):200-204.

Lamb, D.H. and Catanzaro, S.J., (1998). Sexual and nonsexual boundary violations involving psychologists, clients, supervisees, and students. Prof. Psychol., Research and Practice, 29:498-503.

Lamb, D.H., Woodburn, J.R., Lewis, J.T., Strand, K.K., Buchko, K.J., and Kang, J.R. (1994). Sexual and business relationships between therapists and former clients. Psychotherapy, 31:270-278.

Pope, K.S., Levenson, H., and Schover, LR.  (1979). Sexual intimacy in psychology training: Results and implications of a national survey.  Am Psychol., 34:682-689.

Schoener GR, Milgrom JH, Gonsiorek JC, Luepker ET, Conroe RM, eds. (1989). Psychotherapists’ sexual involvement with clients: Intervention and prevention. Minneapolis, MN: Walk-In Counseling Center; 1989;399-502.