Sexual and Other Ethical Boundary Violations in Psychotherapy:
The Victims’ Perspective
Janet W. Wohlberg
Following is the text of a talk given in NYC to the Columbia Analytic Society on April 4, 2006.
What we are exploring today is, for many, one of psychotherapy’s most painful problems. It confirms that therapists, as well as
patients, are subject to the failings of the human condition.
In describing the conduct of certain psychotherapists, I will use what some may consider uncomfortably charged terms, including exploitation, abuse, victim, and perpetrator. While this may seem overly harsh to some of you, I think the terms are accurate and warranted.
To me, this issue is without polemic. When a therapist uses power over a patient to fulfill sexual or emotional needs, it is exploitation; the object of that exploitation is a victim. Just as a therapist has a clear duty not to oblige a masochistic patient who is asking to be beaten, attempts to excuse sexual exploitation of a patient with claims that the patient was seductive are wholly invalid. As attorney Linda Jorgenson points out, “The patient could be a prostitute, naked and begging for it, and it is still always the responsibility of the therapist to set and maintain safe boundaries.”
My story begins in 1972: My husband, a psychiatrist, having been shot by a patient, lay comatose and dying. I turned for support to a psychotherapist. When I confided that among my fears in losing my husband was the concomitant loss of physical intimacy, he offered himself as a substitute. I’m sure that the significance of my being here, 33 years later, talking about what ensued is not lost on this audience. Sexual exploitation by a trusted therapist is a life-changing experience. Like rape and incest, it does not go away. It forms who we are.
In 1987, the Massachusetts Board of Registration in Medicine informed me that my perpetrator had also sexually abused Wellesley College students. In 1988, I joined with four other victims of abuse by psychotherapists to found TELL, the Therapy Exploitation Link Line. In the first decade, with media attention and by word of mouth and referrals from plaintiff’s attorneys and subsequent-treating therapists, approximately 4000 victims contacted TELL, attended meetings and conferences, and wrote and called looking for ways to take action and break the sense of isolation, shame and secrecy that had kept them from healing and moving on. Currently, the TELL website, www.therapyabuse.org, averages about 3600 hits per month.
Over the past 18 years, I have had personal contact with thousands of victims whose stories include the frankly aberrant and the viciously opportunistic:
Among the aberrant have been: the psychiatrist who only had sex with his victim while he was dressed in her clothing; the psychoanalyst who had his victim read “The Story of O” aloud and then acted out the scenarios with her; and the psychiatrist who treated women with debilitating diseases by standing them naked in front of a mirror and performing what he called “vaginal Rolfing.”
Among the opportunistic have been: the social worker who had her client do her office billing and taxes, as well as provide day-care to her elderly mother; the psychiatrist who complained about his high rent and convinced his wealthy patient to buy the building and allow him to remain rent-free; the alcoholic psychoanalyst who served alcohol to his alcoholic patient and then engaged her in day-long sprees of drunken sex; and the psychologist who complained that his victim’s breasts were too small and that he would continue to see her only if she had implants. Fearful of losing him, she complied.
The majority of sexual and other ethical boundary crossings by psychotherapists, however, while all with opportunistic and aberrant nuances, are rarely as blatant as those just cited.
Based on what we have heard from victims, the road from therapist-patient to exploiter-victim usually follows a methodical but generally unperceivable pattern of “grooming.” Most victims become aware of what happened to them only in hindsight and then blame themselves for not having recognized the red flags as they appeared.
Components of grooming include promoting loving and sexual feelings through subtle to obvious words and actions. Victims report therapists telling them sexually charged jokes; therapists making explicit comments about their bodies; therapists moving closer and instituting physical contact; and therapists making graphic statements about sexual arousal.
Patient C, who taped her sessions, actually recorded her therapist saying, “I was just sitting here wondering what it would be like to fuck you.” Significantly, the therapist was aware of the taping but was so convinced of his power over the patient that he was apparently unconcerned.
Grooming also involves separating victims from their support systems and fostering dependence on the abuser as the only one to be trusted indeed, the victim’s only hope for sanity. Victims have been instructed, for asserted therapeutic reasons, to withdraw from their families, spouses, children, and friends.
Abusers pointedly undermine their victims’ beliefs in their job competence, their parenting abilities, and their social skills, while assuring them that they are special but that their “specialness” is understood only by their abusers.
Abusers often move their victims’ appointments to the last of the day and then do not charge for the additional time as a way of further lulling their victims into the belief that the relationship is unique while providing more time for sex. They insist that the special relationship be kept secret, and threaten that disclosure would bring it to an end.
Commonly, the victim is groomed to be the caretaker of both the abuser and the relationship. Abusers have professed to having serious illnesses or dying children or spouses, to being stalked by psychopathic patients, or they may invoke other dire scenarios to elicit sympathy and nurturing. Ed Daniels, the notorious Boston psychoanalyst with 28 known victims, claimed to be facing imminent death from heart disease from as early as his residency years. With apologies to Mark Twain, “rumors of his impending death were greatly exaggerated.” Daniels, who also required his victims to supply the condoms for the sessions at which he had sex with them, died in his eighties
The grooming process may take weeks, months, or years, depending on the patient’s vulnerability. At its peak, the victim is isolated, frightened and confused about her emotional health. Having already invested significant time and money in the “therapy,” she is convinced that her very survival depends on the abuser. Like the victim pushed by her abuser into getting breast implants, she will do anything to maintain the relationship.
With the exception of the infinitesimally rare incidence of the therapist and patient marrying and building a life together, the exploitative relationship comes to an end in one of two scenarios: Either the victim realizes that something is terribly wrong and musters the strength to leave; or, more commonly, the therapist tires of the relationship, no longer wishes to support the dependence that has been fostered, and becomes weary of the growing demands of the victim who, clinging to the belief of being held special, wants to take the relationship to the next level of intimacy with commitment.
This rejection by the perpetrator virtually always involves the cruel denigration of the victim as being inadequate, disturbed, and unworthy or incapable of responding to the abuser’s “heroic” efforts. The already confused victim becomes devastated by the abandonment. 1
Although victims who leave of their own accord appear to fare better in the aftermath than victims who have been discarded, Bouhoutsos et al.2, Gartrell et al.,3 and Pope and Vetter 4 hold that fully 90% of patients who have sex with their therapists are damaged as a result. Victims report: feelings, often intense, of guilt and shame over what took place; feelings of ambivalence towards the abuser who made them feel special, yet used and abandoned them; experiencing generalized, unfocused and often uncontrolled rage; feeling isolated and depressed; and having heightened thoughts of suicide. Moreover, victims report being unable to take care of themselves medically, particularly resisting visits to gynecologists and dentists.
Victims lose the ability to trust either themselves or others, a problem that seriously compromises attempts at subsequent treatment. Victims become hyper-vigilant to anything a subsequent therapist may do that replicates the behavior of the abuser or, in some cases, fails to replicate it. Insistence that the victim needs to trust a new therapist will almost always end a subsequent treatment prematurely. As absolute trust was almost certainly demanded by the abuser, subsequent therapists should avoid appearing to make this demand.
Victims, most significantly, mourn the loss of time, the shortest part of which may have been the period during the abusive relationship. Following the abuse, victims suffer increasingly intense symptoms, the etiology of which may at first be unrecognized. Only when victims make the connection between their symptoms and the abuse, which for some may happen quickly but for others take decades, can healing actually begin.
For many victims, the lost years between abuse and healing include that time when they might have otherwise developed healthy relationships, had children, nurtured the children they had, and advanced themselves educationally and professionally.
Are these profoundly damaging boundary violations inevitable, or are they preventable? Nancy Bridges, in Moving Beyond the Comfort Zone in Psychotherapy, writes:
"...my hopes that education will diminish misconduct evaporate as I understand more about how vulnerable we are as therapists and how great the human capacity is to delude oneself."5
I believe that education is very important, but while it may reduce the scope of the problem, it will not make it go away.
While the majority of psychotherapists will never commit serious boundary violations with their patients, for those who are opportunistic, aberrant, or simply lack essential impulse control, boundary violations such as I have described are inevitable. To paraphrase Bill Clinton, they will do it because they can.
This leaves a gray area, i.e., psychotherapists at the margin for whom ongoing education and mentoring might well make the difference between holding to safe boundaries and stepping over them. The operative word here is “ongoing.” It is unlikely that a two-hour seminar every few years or an on-line, self-administered ethics course will have much impact on a vulnerable therapist, no matter how well meaning.
Recognizing that some boundary violations within therapy settings are inevitable, I have elected to focus my energies on working with victims and on trying to educate consumers about what is and what is not appropriate in psychotherapy. In coming here today, I also hope to add to the knowledge of potential and current subsequent therapists regarding the special needs of their patients who have been abused. Finally, I hope that you will recognize the inevitability of this kind of abuse and demand that the dialogue on this subject be honest and ongoing.
1 Lott, D.L. (1999) In Session: The Bond between Women and Their Therapists, NY: W.H. Freeman and Co., pp. 268-269.
2 Bouhoutsos, J., Holroyd, J., Lerman, H., Forer, R.F., & Greenbeg, M. (1983). Sexual intimacy between psychotherapists and patients. Professional Psychology: Research and Practice, 14, 185-196.
3 Gartrell, N., Herman, J., Olarte, S., Feldstein, M., & Localio, R. (1987). Reporting practices of psychiatrists who knew of sexual misconduct by colleagues. American Journal of Orthopsychiatry, 57, 287-295.
4 Pope, K.S., & Vetter, V.A. (1991) Prior therapist-patient sexual involvement among patients seen by psychologists. Psychotherapy, 28, 429-438.
5 Bridges, N.A. (2005) Moving Beyond the Comfort Zone in Psychotherapy, Lanham, Maryland: Jason Aronson. P. 30.