ethics word cloudIt’s always sad to read about therapists and clients having sex, particularly when it crosses that line between adult and minor, like this recent case.

What makes it sadder: The accused counselor happens to have been the daughter of the program owner– herself in recovery for 30 years.

I’ve seen this sort of thing before, and if you’re a clinician, I’m guessing you have too. It’s hard to get through a career in counseling without encountering at least one such case. When we opened a correctional rehab facility in a southern state, the warden stated flatly to our new hires that before the end of a year, at least one of the female staff would lose her job for having a relationship with an inmate. I remember the women tittered in disbelief.

He was wrong. We had to fire two.

The public finds it shocking but the psychology is pretty well understood. A 1986 study found that 95% of male therapists and 76% of female therapists readily acknowledged sexual feelings on occasion towards some patients “…women therapists were more likely to feel attracted to clients of the same sex than men,” concluded the researchers, while “… male therapists reported having more sexual fantasies than did female therapists, and younger therapists were more likely to have had such fantasies than older therapists.” Few felt they’d received sufficient training on the subject. Yet thankfully, only 7% admitted having acted on those feelings. The rest knew enough not to.

Sometimes it’s just a matter of a poor or inexperienced therapist interacting with a powerfully attractive patient. But there are other factors at work, too. A few possibilities:

  • Rescuing. Clinicians sometimes allow boundaries to erode in the belief that it’s in the patient’s best interest. This happens often with adolescents, because they’re genuinely needy, and prone to view the therapist as a surrogate parent (probably one a lot more understanding than the folks at home). Therapists are taught to maintain a certain detachment, but that can be a struggle in the face of raw need.
  • Overidentification. Therapists often see elements of their own struggles in their patients. Easy to see how that might present a greater risk for someone in recovery, but clinicians relate to patients on more levels than that– an emotionally abusive childhood, for example, or a history of troubled relationships.
  • Seduction. This comes up frequently in correctional settings. Some antisocial people possess a talent for ‘charming ingratiation’– the ability to worm their way into someone’s trust or affection. Both the women in our earlier example cited that as a major factor in their ‘fall from grace’. “He played me like a piccolo,” said one bitterly. Nevertheless, she lost her job and her license.

The ethical boundaries around therapist-patient relationships weren’t always so clear. When I entered the field in the 70’s, such relationships were not particularly rare. Two of our admitting psychiatrists were married to former patients. So long as the patient was no longer formally in treatment, it was considered acceptable, if slightly tainted. ┬áNow the law may require a substantial waiting period, with stiff penalties for noncompliance.

Sexual relations between therapist and patient can seriously damage the public’s trust in the safety of their loved ones. As a field, we need to work hard to preserve that trust. It’s a responsibility we have not just to our current patients, but to future generations of therapists, and the patients they will treat.

“First, do no harm”, said Hippocrates of Kos. He was right.


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