Therapist-Client Sexual Attraction: Ethics & Dynamics

• In 1972, some psychologists controversially suggested sexual relationships with clients could be therapeutic, but this view was exposed as self-serving.
• By the late 1970s, concerns about sexual exploitation led to ethical codes and laws that banned such practices.
• Today, sexual contact with clients is universally considered unethical, malpractice, and carries legal repercussions for therapists.

Sexual Attraction: Therapists and Clients

• Therapists may experience attraction to clients in their careers, eliciting feelings like surprise, embarrassment, and confusion.
• Studies show many therapists (95% of male, 76% of female) have been attracted to a client, though few act on it, with physical appearance and vulnerability as contributing factors.
• Despite high attraction rates, only a small percentage of therapists act on these feelings (9.4% of men, 2.5% of women).
• Therapists should seek consultation and supervision to manage feelings and maintain professional boundaries when attraction arises.
• Clients can develop sexual feelings toward therapists and may express this through suggestive behavior; these feelings result from the intimacy and vulnerability of therapy, not the therapist personally.
• Therapists must set clear boundaries and remain firm if a client makes advances; referral to another therapist may be necessary.

Therapist's Role

• Therapists must assess the intention behind a client's behavior (attempt to control or bond).
• Therapists need self-reflection on their emotional responses.
• The focus should remain on the client's needs, not personal feelings.
• If attraction is recognized, therapists should seek consultation, supervision, and boundary-setting to ensure effective therapy continues.
• Nonerotic touch (such as a brief touch on hand, shoulder, or back) may convey care and emotional support, especially for children or those in distress, and can build trust.
• Risks of nonerotic, physical interactions consist of clients hesitating to express negative emotions
• The concept of nonerotic tough has become more accepted, but therapists remain cautious due to legal concerns and potential misunderstandings.
• Erotic touch is unethical, and touch with the intent of sexual arousal violates professional boundaries; even non-sexual touch can be inappropriate if the intent is sexual.
• Such actions can damage the therapeutic relationship and harm the therapist's reputation.
• Freud warned that although physical affection might address emotional deprivation, it presents dangers of escalating intimacy.
• Affectionate behaviors, such as kissing or hugging, can lead to more serious violations if boundaries are gradually crossed.
• Casual social activities outside of therapy blur professional boundaries.
• Innocuous behaviors like compliments or casual outings can escalate and harm the therapeutic relationship.

Sexual Intimacy with Clients

• Incidence is difficult to estimate due to underreporting.
• Early studies showed 26% of male and 3% of female therapists reported engaging in sexual behavior with clients (1980s).
• Recent data show a decline in incidents due to stricter standards, licensing board actions, and client awareness, but issues persist.

Responsibility and Harms

• Therapists must maintain professional boundaries; client initiation of sexual advances does not absolve the therapist.
• Therapists are responsible for maintaining appropriate conduct, not allowing manipulation or coercion.
• Sexual behavior in therapy damages the therapeutic relationship.
• Emotional Impact: Clients may experience guilt, confusion, and emotional instability.
• Long-term effects include trust issues, identity confusion, and difficulty healing; clients may initially view the behavior as pleasurable but later recognize its exploitative nature.

Clinical Symptoms and Offender Characteristics

• Psychological damage includes ambivalence, guilt, emotional instability, and cognitive dysfunction.
• Identity and trust issues can arise, with clients struggling with boundary disturbances and trusting others; there may also be an increased risk of self-destructive behaviors like suicide.
• Common offender characteristics include feelings of vulnerability, fear of intimacy, crises in personal relationships, feelings of failure, high needs for affection, power and idealizing a special client.
• Poor impulse control, depression, social isolation, overvaluation of healing abilities, sexual identity issues, depression or bipolar diagnoses, or narcissistic traits may be causes
• Denial and rationalization are also commonplace.
• Offending therapists often have strong denial or rationalization defenses and may engage in "rescue fantasies."
• Most offenders are middle-aged men, typically around 15 years older than their clients. Therapists going through personal crises or who were sexually abused are at higher risk.

Client Characteristics and Less Common Scenarios

• Clients exploited are often younger women, some with a history of abuse; same-sex exploitation also occurs.
• Premeditated exploitation involves therapists intentionally exploiting clients, such as through hypnosis.
• More common is manipulation and rationalization, where therapists may try to manipulate clients or justify sexual relations, believing they are offering something beneficial (rescue fantasies).
• Regardless of absence of witnesses during therapy, therapists fear false allegations, as reputational damage can be permanent even if accusations are dropped.
• Additional, similar complaints can reveal patterns of misconduct, potentially leading to further scrutiny and loss of credibility.
• Cases lacking sufficient evidence for a conviction may still lead to significant consequences for the therapist due to damage to reputation and trust.

Prevention

• Therapists should understand client history and psychological functioning.
• Therapists should also document any action or behavior that could be misinterpreted.
• Therapists must maintain professional settings with other practitioners and oversight to prevent misunderstandings.
• Clear professional boundaries must be continuously monitored.
• A therapist’s competence and sensitivity to self-awareness and client needs is vital.
• Some argue that when the conclusion of therapy involves fully informed consent and dissolved trust and power discrepancies, ethical concerns are neutralized.
• It is suggested that policies should avoid unnecessary intrusions into the lives of consenting adults.
• Ethics committees may pursue a case if a complainant presented a compelling argument substantiating improper or irresponsible termination resulting in harm or exploitation.

Ethics and Perpetuity

• In 1992, the APA ethics code revision team proposed a lifetime ban on sex with previous therapy clients based on the risks to clients, practitioners, and the profession.
• The 1992 APA code also defined as unethical any statements or actions on the part of the therapist while therapy was active that suggested or invited the possibility of an eventual relationship with a client. Therapists should refrain from sex with ex-clients even after 2 years post termination except “in the most unusual circumstances.
• Concern exists that a time stamp for post termination sex may alter the therapy relationship from the onset.
• Therapists must remain responsible for any continuing duties and execute them free from conflict and role confusion.
• When the client is a child, it becomes therapeutically and ethically critical to consider the family as the unit of treatment, and meeting with the parents constitutes a therapist-client relationship.
• Educational materials appear to successfully enlighten consumers about inappropriate therapist behaviors and do not decrease trust in psychotherapists.

Supervision and Communication

• Supervisory discomfort with sexual feelings leads to unfortunate communication on the subject.
• Rehabilitation potential is likely related to the type of offender.
• Appropriate disciplinary actions are best decided on a case-by-case basis, and some offenders may be safely returned to practice.
• Those who become aware of a one-time impropriety, experience sincere misgivings, will mediate and cease harmful acting.
• There is potential for criminalization in some states.
• Clients who have been sexually exploited by a previous therapist may never receive competent follow-up help and fear revictimization.
• Treating such clients presents unique treatment challenges.

Supervisors, What to do, and What to Watch For

• Critics of bans on romantic and sexual relationships among faculty and students remain visible, but restrictions designed to prevent conflicts of interest are recommended.
• One must strive to remain self-aware when it comes to your feelings about clients, especially feelings of attraction.
• Therapists should maintain professional contacts with whom to consult about boundary crossings and violations.
• Adequate training and freedom to discuss sexual feelings are also crucial
• Therapists must carefully evaluate clients and their vulnerabilities before touching or engaging with them.
• If crises are present, one may be at risk for harm
• Seeing clients in social relationships must be avoided to prevent mis-communication with clients.

What Not To Do

• Do not be sexually intimate with any current clients
• One must not engage in any acts with clients and students over whom they have supervision duties
• One must never exploit the passivity, kindness, or vulnerability of clients
• To discuss internal feelings, therapists must find an accountability partner
• Working and meeting in isolation must be avoided
• Never engage in relationships with students over whom one has had evaluative authority