Thanks to Gary Schoener for Special Permission to Post His Work
Copyright Gary R. Schoener








The importance of professional boundaries in health care goes back to some of the earliest writings in the Corpus Hippocratum, a body of medical writings housed in the Library of Alexandria in Egypt.  It is likely that the Oath of Hippocrates, created between the 3rd and 2nd  centuries BC with some codes of conduct, was meant to help instill trust in physicians. Even some of the origins of the field of nursing relate to a perceived need to have chaperons present when doctors examined women.  Yet film and popular literature has depicted romantic relationships between all manner of professionals and their clients, creating some public confusion about when and if this is acceptable.  By the early 1970’s, professional boundaries--especially those relating to sexual contact or romantic involvement with clients--became a public and professional issue.  The psychotherapy professions and pastoral counseling arenas were particularly in focus, and many complaints involved those who provided counseling or psychotherapy services. ( Bisbing, Jorgenson & Sutherland, 1995) Return

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The maintenance of professional boundaries has always been a problem and a challenge in the psychotherapy fields.  ( Gabbard & Lester, 1995)  While one might prefer to see people with boundary maintenance problems as a handful of poorly trained or ethically limited persons, this ignores some of the history of these fields.  The early analytic circle in Vienna was rife with dual relationships, violations of confidentiality, and poor boundaries.  Grosskurth’s book The Secret Ring: Freud’s Inner Circle and the Politics of Psychoanalysis and Kerr’s A Dangerous Method are among the many works which detail some of this history.

It is worthwhile to remember this history before we rush to judgment  about our peers and presume that these challenges are easily met. Yet, by the same token, it is important to understand them since they are sometimes improperly cited today as a justification for wrongdoing. Obviously, the fact that in earlier decades famous people had difficulty maintaining boundaries does not excuse modern day wrong doing or violations of current standards.

Melanie Klein, who psychoanalyzed her own children, encouraged patients to come away with her on holiday and then provided therapy while they lay on her bed in her hotel room.  Ernest Jones had Klein analyze his children and wife.  Certainly many in the early analytic circles analyzed each others family members, mistresses, etc.  Sigmund Freud analyzed his own daughter, Anna Freud, who later indicated she felt upset by his use of her clinical material for teaching well after she had become a professional in the field.

Many key contributors to the field of psychotherapy and psychoanalysis have had a romantic or sexual involvement with a current of former client---in some cases a client who was in training or already in the field him or herself.  Carl Jung had a personal and romantic involvement with Sabina Spielrein, a young medical student who came to Jung struggling with serious emotional problems and then went on to a brilliant career in psychoanalysis, cut short by her murder by the Nazis on 27  July 1942.  The historical record suggests that Jung helped her considerably, although doubtless also injured her. During a now famous interchange of letters with Freud, Jung acknowledged his misdeeds, only to have Freud blame Spielrein.  The involvement between Jung and Spielrein was not a singular one in early analytic circles:

Jung was scarcely the only person to become involved with a patient.  Gross’s exploits were legendary, Stekel had long enjoyed a reputation as a “seducer,”  Jones was paying blackmail money to a former patient, the even good Pastor Pfister was lately being entranced by one of his charges. Indeed, the most extraordinary entanglement was Ferenczi’s, the amiable Hungarian having taken into analysis the daughter of the woman he was having an affair with and then fallen in love with the girl.  Freud in fact was then currently seeing the younger woman at Ferenczi’s request in an attempt to help rescue the situation.  That Spielrein had once been Jung’s lover would not have disturbed Freud at all. (Kerr, 1993, p.379)

Freud’s reference was to Ferenczi’s involvement with Elma Palos (the daughter of his future wife Gisella Palos), whom both he and Freud had treated, in the now famous letter from Freud to Ferenczi of 13 December, 1931 containing Freud’s criticism of Ferenczi’s kissing of patients.  Although this exchange is often used to suggest that Freud was a stickler on boundaries, the historical record shows otherwise.  Furthermore, Freud was providing private information to Ferenczi in an apparent attempt to influence his choice of a mate.  In addition, for many years the extent of Ferenczi’s misconduct was not widely known because Ernest Jones’ widely-read translation of this letter, significantly, omitted Freud’s attempt to connect the kissing of patients with what he termed Ferenczi’s “old misdemeanors”, “...the tendency to sexual playing about with patients...”.  For his part Ferenczi replied to Freud in a letter dated 27 December 1931:

“The sins of youth,” misdemeanors if they are overcome and analytically worked through, can make a man wiser and more cautious than people who never even went through storms...Now, I believe, I am capable of creating a mild, passion-free atmosphere, suitable for bringing forth even that which had been previously hidden. (Masson, 1984, p.160)

Ironically, while at the University of Toronto, Ernest Jones became the subject of an allegation of sexual involvement with a client.  He had not only initially denied the involvement but attacked the woman’s general practitioner who had assisted her in making the complaint.  However, when it was revealed that her attempted to pay “hush money” to get the client to withdraw her complaint it was decided that he was guilty of the offense.

Another example of the problems in maintaining professional boundaries is provided by the experience of famous psychotherapist Margaret Mahler: almost three-year analysis with Aichhorn, while helpful in many respects, was far from “classical.”  For the fact is that Aichhorn and I were, by this time, very much in love with one another, making impossible the classical relationship between analyst and analysand.  In taking me under his wing and vowing to see me restored to the good races of the Viennese psychoanalytic establishment, Aichhorn only buttressed my self-image as an “exception”--now in an entirely positive sense as opposed to the negative sense inculcated by Mrs. Deutsch.  Under Aichhorn’s analytic care, I became a sort of Cinderella, the love object of a beautiful Prince (Aichhorn) who would win me the favor of a beautiful stepmother (Mrs. Deutsch). At the same time, my analytic treatment with him simply recapitulated by oedipal situation all over again...

By the time Aichhorn intervened and secured my readmittance to the institute training program some six months after our analytic work began, I was his favorite pupil.  As our personal relationship blossomed, I became his lover as well. ( Stepansky, 1988,  pp. 68-69)

Famous women analysts were also at times in charge and their male trainees or clients were the subject of their personal interests.  Frieda Fromm-Reichmann has written that her husband, Erich Fromm, was a patient when they became romantically involved, noting that at least they had the “ common sense” to terminate the therapy before marrying.  Even today, it is widely known but rarely discussed, that a number of key figures in the various psychotherapy fields are married to former patients.

Karen Horney is alleged to have had sexual relationships with candidates at the analytic institutes with which she was associated in both New York and Chicago, “including supervisees and analysands” such as “Leon Saul, who was traumatized by the experience”(Paris, 1994, p.142).  She had been described at times as behaving much like the stereotype of the “dirty old man” who plays “sexual politics.  “Horney’s lovers sometimes became favorites to whom she gave power, until, to their pain and bewilderment, she turned against them.  She then replaced them with other favorites.”(Paris, 1994, p. 143)

Otto Rank reportedly became sexually involved with a former patient.  Freud himself encouraged Horace Frink, a young analyst whom he was treating, to follow his desires and divorce his wife so he could marry a patient.  Freud may have had financial motives in this case, hoping for a donation to the psychoanalytic movement from the patient’s wealthy family.  The outcome had some very negative consequences for those involved. Frink, who was a rising star in the American psychoanalytic movement became disabled and unable to practice and his patient ended up very unhappy as his wife. Others who were peripherally involved were also harmed.

Even today a small group of writers is challenging the cultural and professional zeitgeist about professional boundaries.  Rev. Carter Heyward, in her book When Boundaries Betray us, argues that her psychotherapist “betrayed” her by not being willing to be involved in a post-therapy friendship or intimate relationship.  Psychotherapist and author Miriam Greenspan (1995), in her article “Out of Bounds,” argues that rigid therapist-patient boundaries are consequences of  the Heyward viewpoint in Katherine Ragdale’s Boundary Wars.

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Over the past decade the concept of the dual relationship, or more current term of multiple relationship, has become a commonly used concept in the professional boundaries arena.  There has been a tendency to equate this with inappropriate intimacy. Sonne (1994) has argued that despite various revisions, the Ethics Code of the American Psychological Association, where this concept first appeared, still does not clearly define multiple relationships or define when they are harmful.  Coale (1998) has raised some similar concerns for the field of social work.

However, contacts with clients outside of the professional relationship are not limited to true dual or multiple relationships where there is a conflict of interest and the professional relationship can be undermined.  There are also overlapping relationships where there is not really a significant role conflict, and also encounters with clients outside of the treatment setting.  Even encounters vary as to significance, and our own experience as well as some of the research suggests that professionals are far more concerned about encountering clients than are current or former clients worried about encountering them.  In fact, we have ourselves made the mistake of “processing” an outside contact with a client in a fashion which caused her to simply be angry at us for intruding on the treatment with “our hangups.”  The following example will provide some clarity about how we differentiate encounters, from overlapping, from multiple (dual) relationships:

I ran into a client in a church parking lot and said “hello.”  [Encounter] I noticed that the client, although she rarely attended, was a parishioner in the same church as our family [encounter, but with the possibility of an overlapping relationship].  The client signed up for the same Sunday school class, one which involved simply hearing lectures and occasionally discussing readings about the gospel.  [Overlapping] The pastor announced the formation of a marital support group designed to improve marital relationships and my spouse and I signed up, but in the first session we discovered that the client and her spouse were members, something of  great concern since participants were to be talking about their marital life. [Multiple relationship]

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Borys (1988) compared social workers, psychologists, and psychiatrists who admitted to sex with clients to those  who didn’t on a number of self-reported boundaries issues. Despite the fact that 40 of her 44 offenders had a post-termination sexual relationship (which one would have expected to have brought about agreement on a number of items on her scale), she could only correctly classify 55% of the erotic practitioners and 79.4% of the non-erotic when comparing them on her Social Involvement Scale, which included the following items:

Borys (1988) also found considerable variability within the psychotherapy fields as to what is deemed acceptable in a number of areas.  For example, therapists’ responses to the following boundaries questions yielded the following very varied opinions:

Accept a gift under $ 10:  

  • 19.5% never, 53% several, 10.4% all clients

Accept invitation to client’s special event:

  • 50% never, 22% few, 3.4% some

Becoming friends after termination:

  • 65%  never, 23% few, 3.3% several clients

Treating an employee:

  • 57% never, 12.8% few, 3% some clients

Disclose own stresses to client:

  • 59% never, 26.8% few, 9.7% some, 1.3% many

Invite to open house:

  • 50% never, 5.7% few, 6.7% some, 2.7% many, 3.4% all

Lamb & Catanzaro (1998) in a national study of psychologists compared a group which acknowledge sexual boundary violations with either clients or students and supervisees. (76% of the group reported violations with clients).  Nonsignificant differences were found between this group and those who did not acknowledge sexual boundary violations on a great many questions, including:

Initiating non-sexual touch with a client 

  • (60 vs. 66% did this)

Discussing details of a current personal stressor to a client

  •  (42 vs. 56% did this)

Going to a client’s  special event 

  • (e.g. wedding, funeral of a family member, art show, etc.) (56 vs. 62% did this)

Sending holiday greeting card to your client(s) 

  • (18 vs. 20% did this)

Lending less than $ 10 to a client 

  • (10 vs. 15% did this)

Renting an apartment / house to a trainee under your supervision 

  • (less than1% did this)

Very few respondents in either group reported employing a client at their agency, having a current trainee obtain therapy at their agency, or serving on a thesis or dissertation committee of a current supervisee.  It may be noteworthy that 8% of non-offenders and 16% of offenders reported having a current employee obtain therapy at your agency.

 Two other significant differences were found in:

Developing a business relationship with a former client 

  • (6 -18% did this)

Giving a client theater, sports, or other “event” tickets that you learned at             the last minute you could not use 

  • (4 -16% did this)

Some significant findings of differences also reveal relatively high numbers of both offenders (those who admitted to sexual boundary violations with a client, student, or supervisee) and non-offenders admitting having engaged in:

Becoming social  friends with a former client 

  • (66% of offenders, 27% of non-            offenders) 

Going to a small social gathering when you know your client will be there

  • (58% of offenders, 43% of non-offenders)

Remaining at a party after accidentally encountering and interacting with a client at that party 

  • (72% of offenders, 50% of non-offenders)

Crying in front of a client 

  • (56% of offenders, 39% of non-offenders)

 When I examine this data I am more struck by the lack of large differences than their presence, and also the relatively high numbers of non-offenders who engage in potentially risky management of boundaries.

Depending on the school of therapy one belongs to a particular boundary may be more or less important.  For a behaviorist to visit a client’s home to perform an en-vivo desensitization may be quite proper, or a family therapist to do sessions in the home may be fine, whereas for a psychoanalyst to make a home visit might be a boundary crossing.  This is brought into sharp focus when we do workshops on boundaries and use the exercises such as What’s OK, What’s Not OK, What Maybe OK? And Personal vs. Professional (Milgrom, 1992).

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In the 1950’s and the 1960’s concern in the counseling field was about genuineness, warmth, “connecting with the client.” Researcher’s studied these things and their impact on therapy and counseling. Concern was about the “distant” or “uncaring” practitioner.  By the mid-1970’s into the 1980’s the concerns were about intrusiveness, exploitation, and abuse-- all seen as a consequence of over-involvement.  Studies have shown that either extreme can be harmful, and when therapists themselves are studied, those who have bad experiences in their personal therapy suffer from therapists at either extreme. Coale (1998) and others have examined this issue.


Distant/Cold/formal/aloof            ZONE OF                    Intrusive/Over-Involved

My therapist didn’t care;             HELPFULNESS       My therapist tried to run my life; I should have left therapy--                                 My therapist had sex with me;
I never felt support or caring                       My therapist wanted to be my mentor


The key is to be somewhere in the ZONE OF HELPFULNESS, whether one tends to be more formal, or one tends to be more emotionally involved or in greater physical contact.  Distance per se cannot be equated with appropriate professional work, just as warmth and caring, and even touch cannot be equated with professional misconduct.  Recent writings on the use of touch in therapy have helped focus this discussion. (Hunter & Struve, 1998; Smith, Clance, & Imes, 1998)  But there are not precise rules about many of  these boundaries and there is considerable variability in the various psychotherapy fields.

If we examine a broader range of health care fields, the use of touch varies considerably.  Touch may in fact play a key role in healing. Likewise, rules about other types of contact in the community may be less strict than they are for the psychotherapy professions.  The American Medical Association standards for dating a patient of a non-psychiatric physician, for example, allow for pursuit of a romantic interest as long as the professional relationship is terminated and some care is taken.  However, if there has been psychotherapeutic treatment, the standard of the American Psychiatric Association are to be followed, which forbid such a relationship in perpetuity.

Examining other boundaries, the site where service is normally delivered may be in the home for a personal care attendant, public health nurse, or some other professionals. Clergy are often in a position to interact with their congregants (including their counselees) in a number of settings and may have considerable social interaction with them.  Physicians and other health care professionals who live in small towns may experience far more social interaction between their families and those of their patients than those who practice in large cities.

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The failure to maintain professional boundaries or the violation of boundaries can take a great range of shapes and occur for a great variety of reasons.  This can involve all types of over-involvement with clients including social contacts outside of the professional relationship, gifts, involving oneself in the client’s life, confidentiality violations, excessive anger, physical contact, romantic game-playing, erotic talk, sexual contact, and numerous other things.  Some of the things which may have brought about a crossing of boundaries include:

  1. Inadequately Trained: This may reflect a general lack of training relative             to boundaries or a specific lacunae in the training as regards relationships with clients or patients;

  2. Poorly Trained for the Particular Role or Job:  The professional may have good training, but not for the role which has been undertaken. He or she may be over their head in terms of the demands of the job.  Some practitioners from large urban settings have great difficulty functioning in rural settings where they are expected to perform a much wider range of functions.  They also encounter their clients or patients more frequently outside of the office.

  3. Those whose job description is inadequate or who may have been    poorly oriented to their job role: Some workers get into trouble in situations       where the lack of good job and role definition and lack of good orientation and  supervision sets the stage for compromising situations.  This is commonly seen in church settings, but is surprisingly common also in health care settings;

  4. Those who lack good supervision at their worksite or who fail to use the supervision that is available to them: Some job situations lack the necessary of itself this does not “cause” boundary violations, it can help set the stage, or fail  to provide for early intervention so that the problems become worse.

  5. Those who lack awareness of transference/countertransference in general, or in a given situation: Some professionals are not aware of their areas of vulnerability and lose their boundaries with certain clients.  Some clients, such as those with Borderline Personality Disorder, or persistent multiple complaints, or factitious disorders, may represent challenges to a wide range of professionals.

  6. Those who have excessive need for client or patient approval:  Professionals who are insecure and who will do anything to gain client approval have great difficulty setting limits.  Some very solid practitioners will experience periods in their life where the loss of important relationships, or even problems at work, will undermine their self esteem and lead to an excessive need for client or patient approval.  This can also happen with clergy and parishioners. 

  7. Those who are naive and lacking in good social judgment: Some  workers appear to lack the “social intelligence” necessary to be a professional, or or do not wish to be in the professional role. They deny the power differential and             responsibility that goes with the professional role and would like to function more    like a friend.

  8. Practitioners with organic impairment: Although uncommon, some             professionals are impaired due to brain injury or other organically-based             impairment. Alzheimer’s and other organic disorders in more senior practitioners can have an impact on professionalism.  Such impairments may represent a problem which cannot be repaired by supervision.  Over-medication can also, at times, create such problems.

  9. Practitioners with impaired judgment secondary to addiction or             alcoholism: Substance abusers and alcoholics may have judgment that is impaired due to their varying mood states or intoxication. I n this extreme, acute toxicity can  be a problem. In the later stages of alcoholism and of certain types of drug addiction one may also suffer organically based decline in judgment.

  10. Psychopathology: Beyond the psychopathology inherent in some of the             previous points, it may turn out that the worker has any of the following problems:
    Schizophrenia or Severe Borderline Condition: Troubled thinking or a lack of impulse control based on an underlying thinking disorder.  May also be quite paranoid and do considerable projecting.
    Mood Disorders: Bipolar disorders can lead to dysfunction due to manic or depressive episodes.  Other depressive illnesses can impair judgment.
    Predators with Psychopathology-- Sociopaths or Severe Narcissistic Personality Disorders: Self centered and exploitative by nature, these workers seek to manipulate to get their needs met.
    Impulse Control Disorder: This can be a sexual impulse control disorder or a more general problem, often combined with an addictive problem.

  11.  Emotionally Needy & Dependent: There are a number of problems  associated with low self-esteem and high dependency needs, which lead             professionals to be highly needy of client acceptance on a long term basis. These professionals seek to meet their needs through their clients. This category overlaps with Dr. Glen Gabbard’s concept of Lovesickness but includes others who are just plain needy.

  12. Situationally Needy or Impaired  --  the “Wound Healer”: Due to acute             situational depression, a life crisis, or other more transitory problems, a             professional becomes situationally needy and at risk to cross boundaries.

  13. The professional as a superhero: Practitioners who are driven to be             “perfect” or do everything for clients, ironically, may begin taking risks while             rationalizing that they need to try “everything” that might help.

  14. The practitioner who surrenders to the client: Similar to Gabbard’s             concept of masochistic surrender, the practitioner who has a history of being dominated in relationships and feeling frustrated about it, who allows a client to manipulate and dominate and then who is consumed by resentment about this fact.  Again, this situation is often created when a client or patient is continually resistant to change or “cure”.

The categories above are not mutually exclusive. In most cases there are multiple determinants. The key is to determine what the pattern is, if any, and why it occurred.

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We evaluate students and trainees with boundary problems in the same fashion as practicing professionals in the same field.  Student impairment is certainly related to the maintenance of boundary issues (Lamb, 1999; Schoener, 1999) and the APA Advisory Committee on the Impaired Psychologist has repeatedly made this point (Schwebel, Skorina, & Schoener, 1988, 1994).

 Forrest, Elman, Gizara, & Vacha-Hasse (1999) have provided an exceptionally well developed discussion of this issue which is followed by commentaries from others.  The long-standing practice of simply sending students for psychotherapy, or disciplining them and providing them with tighter supervision, is not adequate.  Any plan, as with practitioners who offend, needs to be based on a comprehensive assessment.  Thus, the model presented herein is used with students and trainees in the same fashion as it is with those already out in the field.

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Prior to the last decade sexual misconduct and related boundary violations by therapists and other health care professionals was often treated with an attitude of tolerance.  Offending professionals received mild discipline, returned to practice while receiving some sort of psychotherapy or counseling and possibly supervision of their work.  It was often assumed that they would not repeat.  Typically no formal assessment was done to determine rehabilitation potential.  A number of psychotherapists and counselors were apparently willing to undertake the treatment  of such cases with only limited knowledge of the original offenses and without a clear plan for how a repeat of the behavior was going to be prevented.  The focus of such therapies was whatever the offending therapist wanted to discuss.  Often the professional misconduct received little or no attention.  The etiology of the unprofessional conduct might not even be identified.  Professionals often were deemed “cured” after a course of  therapy which largely addressed distress and/or depression which was secondary to having faced discipline.

Even when a more targeted approach was taken to the planning of a rehabilitation effort, a subsequent employer, board of licensure or registration, or college might undermine the plan. It is quite common, even today, for example, for a practitioner to be required to obtain a clinical intercept or a very formal type of supervision but be unable to do so.  The practitioner then appeals to the licensing or regulatory authority which relents and allows a lesser level of training or supervision.  For example, in a case described by Bates & Brodsky:

But the board did not hold to the original five mandates. The results of the psychological evaluation ordered in the first mandate may not have offered great promise for rehabilitation. The second mandate had to be altered: Dr. X could find no clinical internship program that would admit him...They lifted the requirement of a clinical internship. In its place, they  set out a requirement that Dr. X practice under the supervision of a licensed psychologist for 2 years, or at least 1500 hours per year. (Bates  & Brodsky, 1989, p. 80)

In many situations in the USA and elsewhere licensure and regulatory boards have designed rehabilitation plans without an independent outside assessment.  As such it is difficult to judge situations I which some sort of therapy and/or retraining and supervision have been prescribed and failed to prevent a reoccurrence of the offense.

Last but not least, in recent years regulatory bodies in North America have been experimenting with “boundaries training” and boundaries and ethics coursework to supplement, or replace personal therapy for offenders.  This use of a broader range of interventions has been embraced by a major study done for the Maryland General Assembly (Nugent, Gill & Plaut, 1996).  Recently debate as to the value and efficacy of this  practice become a public issue in the New York Times Magazine story Dr. Smith Goes to Sexual-Rehab School (Abraham, 1995). The Minnesota Board of Social Work, in 1998, contracted with four groups to which social workers who had committed boundary violations were referred for boundaries retraining. Our center and the other three service providers each utilized a different approach.

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While it might seem reasonable to presume that rehabilitation involves an attempt to alleviate conditions which led to the original misconduct so that the likelihood of a repeat offense is greatly lessened or eliminated, the term is often used to mean other things.  It has been noted that: Rehabilitation as it is sometimes now practiced serves more as a minor form of punishment, perhaps to expiate the guilt of the offending therapist and, maybe even more, of the sanctioning committee or court. (Brodsky, 1986. P.164)  We use it to mean a planned attempt to return a social worker to previous levels of functioning and competence and to lessen or eliminate the likelihood of misconduct, boundary crossings, or substandard work.

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Some victims and victim advocates oppose rehabilitation, seeing it as a way of avoiding disciplinary consequences, or as not being sufficient to redress the harm done by the offender.  Others, including some in the health care professions point to ill-fated efforts to treat and rehabilitate those who are not motivated, or are not able to change. The news media often raise a concern about whether is appropriate in cases of particularly bad professional violations, or whether it is done based on an assessment, or some second-guessing by a board of regulation. (E.g. Wendling, 1999). Gonsiorek & I have raised these concerns for many years (e.g. Gonsiorek & Schoener, 1987).

I doubt that any among us would not challenge an attempt to rehabilitate a professional who did not: 

  1. admit guilt; 

  2. express remorse; 

  3. indicate a strong desire to change. 

Likewise, we would require a competent and thorough evaluation which found the practitioner to be potentially treatable. However, with boundary violations which are not frankly sexual, the professional’s problem may include a lack of understanding as to where a line is crossed, so conditions (1), (2), and (3) above need to be reviewed in the context of the case.

Beyond the concerns voiced about the lack or inadequacy of assessments and trying to treat people who are not treatable, one author, Pope, has authored numerous publications which unequivocally oppose rehabilitation aimed at returning to practice therapists who have had sexual contact with a client, going so far as to declare that this represents a violation of the Nuremberg Code developed in response to Nazi experiments (Pope, 1994).  Allowing rehabilitation in this view, is equivalent to a member of the board regulating the use of a pesticide (who is charged with protecting the public) minimizing the risks of the pesticide chlordane (Pope, 1994, p.37).

A keystone of this argument against rehabilitation is the repeated contention that there is supposedly an 80% “recidivism” rate among therapists who have had sexual contact with clients, with reference being made to Holroyd & Brodsky (1977) who have found that 80% of a group of psychologists who acknowledged sex with clients indicated that it had been with more than one.  A second citation is to “data” cited in a brochure  developed by the California Dept. Of Consumer Affairs (1990) which does in fact give the 80% figure, but correctly labels it as the percentage of therapists in one study who acknowledged repeat offenses.  This is simply another reference to Holroyd & Brodsky (1977). No mention is made of a far more recent study which found that only one third of psychiatrists acknowledge repeat offenses. (Gartrell et. Al., 1987) or similar data from Australian (e.g. Leggett. 1984) or British work (e.g. Jehu, 1994). A citation is also made to Butler’s (1975) Ph.D. dissertation which involved interviews with 20 therapists who admitted sex with clients, 75% of whom reported sex with more than one client, although 95% indicated that they did not want to do it again. It is unclear from the study whether this 95% whether who did not want to offend again were able to prevent a reoccurrence.

None of this data, of course, reflects on failed rehabilitation efforts per se. It does not represent “recidivism” in the usual meaning of the term-- that is, repeat offenses following some intervention ( either punishment, rehabilitation, or both).  Beyond the dictates of professionalism, there are additional issues which can be raised about any approach which seeks some “across the board” solution to such a multifaceted phenomenon:

...any attempt to understand the phenomenon of sexual misconduct requires a detailed examination of the characteristics of therapists who have become involved in sexual transgressions. A fair-minded and scientific assessment of these therapists has been hindered in recent years by the increasing politicization of the problem of sexual misconduct. In some segments of the mental health professions there is an insistence on a “politically correct” view of the phenomenon that ascribes all sexual misconduct to evil and thoroughly corrupt male therapists (Gabbard, in press: Gutheil & Gabbard, 1992). This perspective may have particular appeal to other practitioners of psychotherapy, who can reassure themselves that those colleagues who transgress sexual boundaries have characteristics that set them apart from all other therapists. The problem can thus be solved by eliminating these “bad apples” from the various professions. 

This politically correct model depends on the projective disavowal of the universal vulnerability to sexual transgressions that is inherent in anyone who practices in the mental health professions. The most sensible approach is to assume that we are all at risk for boundary violations under certain circumstances.....All systematic studies of psychotherapists who have been involved in sexual boundary violations indicate that sexual misconduct occurs among a diverse group of clinicians who become involved with patients for a variety of reasons. Any attempt to lump all the transgressing therapists into one politically correct category is reductionistic and misguided. Gabbard (1994, pp. 438-439)

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Loss of a license, registration, certification, or job can be prescribed as discipline or punishment for sexual misconduct, quite apart from public safety concerns. The goals of discipline (or punishment) are typically the following:

  1. To reinforce a standard or underline the seriousness of an offense.

  2. To deter the offender from repeating his or her offense.

  3. To deter others from committing a similar offense.

  4. For justice and/or to maintain the integrity of the profession.

In most instances the question is NOT punishment versus rehabilitation. In fact, consequences may be a key ingredient in bringing about a successful rehabilitation. License suspension or leave from a job may be important for public protection until rehabilitation can be completed and judged as to its success.  Disciplinary consequences and rehabilitation are not mutually exclusive.  Rehabilitation should not be used as a mild form of punishment.

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Figure 1 (at end of paper), an overview of the assessment process, provides a diagram of the framework and methodology utilized.  The overall approach used is a rule-out approach the assessor attempts to rule out serious pathologies. The assessment involves a parallel assessment of both professional history and functioning and personal history and functioning.  Both psychological testing and interviewing are done, but this approach does not rely exclusively on traditional tools.  It is designed to understand behavior which often has multiple determinants, not simply to find a diagnosis or to classify the practitioner into a category.  Others who have utilized our model, such as Celenza (1998) also report great variability in the determinants or even sexual misconduct.

The unique feature of this approach is the emphasis on attempting to gain detailed background data through an interview of the victim or complainant. This involves interviews, usually over the phone, with one or more victims or complainants who present a first hand account of their memory of the events. This is sometimes done even when the events happened years earlier.

It is our belief that an interview of the complainant greatly enhances our ability to understand the situation for at least three reasons:

  1. It is less likely that one can be deceived about what happened;

  2. Even when the professional is trying to tell the truth, defensiveness may lead to denial or minimization;

  3. Even with a very cooperative subject the person being evaluated only knows part of the story of what happened -- each person stores the information differently.

Much like the situation with visual perception where one needs two eyes to see in three dimensions, and where the discrepancy between the view granted by each of ones eyes create the three dimensional view, having information from both parties provides a much richer picture.  This combines traditional psychological assessment which seeks to predict behavior from personality with the approach utilized by criminal profilers who seek to predict personality from behavior under this principle, that to know an artist one would do well to examine his work (see for example Douglas & Olshaker, 1995). Some other approaches to assessment and treatment follow.

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More traditional sex offender treatment programs have been a resource for some professionals who have engaged in sexual misconduct for some years now. Until recently little has been published on their extensive work with professionals who have engaged in sexual misconduct.  Typically they tend to focus their evaluation on identification of sexual impulse control disorders as presented in the DSM IV.  Since some professionals who have offended against clients do not show the same compulsive behaviors as other sex offenders, these programs take into account the behavioral circumstances of the offense(s) in an effort to devise a rehabilitation strategy. As such, work such as that of Abel and colleagues focuses on “developing skills to decrease arousal, including the development of safeguards to attempt to prevent the professional from ending up in a high risk situation again,” paralleling the authors’ work with other types of sex offenders but extending it considerably (Abel, Osborn, & Warberg, 1995).

The cognitive behavioral approach has been researched extensively, although its application to professionals who have offended is more recent and not as well researched.  Psychophysiologic measures such as the penile plethysmagraph may be utilized in diagnosis or evaluation of treatment outcomes.  Typically a period of evaluation and intensive treatment is followed by a structured aftercare program, including cognitive-behavioral therapy, re-education, and a strong emphasis on relapse prevention.  Sometimes a client satisfaction or quality assurance type questionnaire is given to patients to attempt to assess whether violations are continuing.  Examples of re-entry plans and procedures are available in the literature. (Abel, Osborn, & Wargerg, 1995; Schoener et. As., 1989).

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Strean’s (1993) book Therapists Who Have Sex With Their Patients: Treatment and Recovery does not rely on any sort of typology.  One of his cases involves a “sadomasochistic social worker who makes his female ex-patients suffer.”  The overall approach is psychodynamic and individualized.  One of the three cases involves a female therapist.  Claman (1987) and others have also presented cases analyzed from a dynamic or psychoanalytic perspective.

 Gabbard (1994), based on extensive clinical experience with offenders at the Menninger Clinic in Topeka, Kansas, sorts offenders into four groups:

  1. psychotic disorders;

  2. predatory psychopathy and paraphilias;

  3. masochistic surrender-- a “giving in” to a challenging or difficult client, hoping to mollify the client by being flexible with boundaries;

  4. Lovesick: Within the “lovesick” category he notes a number of issues or dynamics which singly, or in multiples, play a role in the misconduct. These may also be factors in the other three categories also. :

    1. Unconscious reenactment of incestuous longings

    2. A wish for maternal nurturance is misperceived as a sexual overture

    3. Interlocking enactments of rescue fantasies

    4. Patient viewed as idealized version of self 

    5. Confusion of therapist’s needs with patient’s needs

    6. Fantasy that love, in and of itself, is curative

    7. The exception fantasy

    8. Repression or disavowal of rage at patient’s persistent   thwarting of therapeutic efforts

    9. Anger at organization, institute, or training analyst

    10. Manic defense against mourning and grief at termination

    11. Insecurity regarding masculine identity

    12. Patient as transformational object

    13. Settling down the “rowdy” man (the notion that the “right woman” can fix even the most character disordered man)

    14. Conflicts around sexual orientation

Treatment efforts are focused on the “lovesick” category as well as those in the “masochistic surrender” grouping which includes therapists with masochistic and self-destructive tendencies who essentially allow clients to intimidate or control them.  The psychotics and the predators are not deemed good subjects for rehabilitation.

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Another approach to assessment and treatment of those who cross sexual boundaries has grown out of the work on sexual addiction.  This literature has been rapidly expanding in recent years (Irons & Schneider, 1999). While the typical sexual addiction program seeks to identify addictive or compulsive aspects of sexual behavior and classifies a wide range of individuals into this single category, a more complex theoretic has been developed by Irons.  This model presumes that some professionals who engage in sexual misconduct do not have a paraphilia or psychosexual disorder as defined in DSM IV.  The model takes into account the parallels with incest in such relationships and relates the acting out behavior to an attempt to cope with inner wounds (they report a high percentage of abuse victims among the professionals they evaluate). They also frequently find other addictions to be present  (Iron & Schneider, 1999).

Extending the addictions approach, Irons presents a set of “archetypal categories” which are reminiscent of a Jungian approach to personality, and attempts to use them to further describe offenders. Irons & Schneider (1999) found the following when they applied these categories to a sample of 88 sexually exploitative health care professionals they found different percentages fell in each group, and that the percentage in each category who was diagnosed with sexual addiction also varied considerably:

The naive prince -- early in career, feels invulnerable, tends to develop “special relationships” with certain types of clients & blurs boundaries [7.9% overall but       none of the sex addicts in this category]

The wounded warrior -- overwhelmed by demands, overly dependent on   professional mantle for validation--patient involvement=temporary escape [21.6% overall, with 37% in this category judged to be sex addicts]

The self-serving martyr -- middle or late career; work is primary; withdrawn, angry, and resentful [23.9% overall, with 62% in this category judged to be sex addicts]

The false lover -- enjoys living on the edge, the “thrill of the chase”--a risk-taker who desires adventure [19.3% overall, but with 94% in this category classed as sex addicts]

The dark king -- powerful & charming ; successful, manipulative--sexual exploitation as an expression of power [12.5% of sample, but 91% in this category were diagnosed as sex addicts]

The wild card -- erratic course in person & professional life; significant difficulties in functioning-- has major Axis I disorder [14.8% of the total sample, with only 23% judged to be sex addicts]

The assessments done utilizing this approach are inpatient assessments for the most part.  The presumption is that the intensity of the evaluation and milieu will penetrate denial and other defenses and reveal the underlying problems.  This approach can be utilized with a resistant person who does not fully acknowledge the degree of dysfunction.  Dr. Irons and Dr. Jennifer Schneider have collaborated on a fine book, The Wounded Healer (Irons & Schneider, 1999) which is the best summary of this work and this approach.

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Despite the substantial differences in approach, as compared with traditional psychological evaluation, each of these assessment methodologies involves the collection of far more background data from persons other than the person being assessed.  Each involves obtaining of behavioral description of the events in question and each one requires a good deal of cooperation.  Each approach recognizes that some offenders lie or minimize, and also that some will seek these assessments in order to attempt to avoid consequences.  Each believes that some offenders cannot be rehabilitated and recognizes the need to counsel some people out of the field.

Each pays some attention to the dynamics of the professional relationship and assumes multiple determinants in the typical case.  Each presumes that public safety is a key issue, and each involves an initial diagnostic decision, a treatment plan, and an eventual evaluation after treatment is concluded to assess whether it was successful.

All of these approaches presume that professional retraining of various types may be necessary and that skill and training issues may be as important as psychopathology in some cases.  However, as was noted by several speakers at a symposium on “Sexual Misconduct: Therapist Evaluation and Rehabilitation” at the 1994 Annual Meeting of the American Psychiatric Association (Lazarus, 1994), “knee jerk” referrals for retraining or supervision are no more useful than referrals for therapy. One needs to be quite specific as to what deficits in skills or training are present and why the specified course of retraining is expected to remedy the situation.

Each involves the use of supervision and the development of a re-entry plan with possible practice limitations. However, all stress the importance of clearly defining the supervision. It is critical that its goals and requirements be spelled out in detail, and that case consultation (voluntary sharing of clinical material, often termed “supervision”) be differentiated from true supervision wherein the supervisor is legally responsible for the practice oversight.

In recent years some licensure boards have taken to requiring “ethics consultation” which involves regular meetings, often monthly, with an “ethics consultant.” It is unclear what this is expected to accomplish in that in most misconduct cases there was no lack of understanding of professional ethical standards. We have seen this required of professionals who teach ethics or have served on ethics committees, and in situations where knowledge of ethics was in no way lacking. That is, in situations where the practitioner was completely clear as to what was being violated. “Boundaries training” has also been added to rehabilitation plans (Abraham, 1995), but again this is often not clearly connected to why the misconduct occurred. Even referrals for ethics coursework, meetings with an ethics consultant, or boundaries “training or coaching” should have their justification in the findings of an independent assessment. There is no less rationale needed for such a referral than for a referral for therapy.

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A number of these models typically lead to a specific treatment approach. Gabbard’s involves psychodynamic therapy or psychoanalysis and Iron’s typically involves treatment for an addiction of one type or another.  Abel’s model is focused on cognitive-behavioral therapy and may utilize some psychophysiological instrumentation. Our model is not particularly tied to any given therapy approach, although Gonsiorek (1995) has articulated his own approach to therapy with some offenders.

Note that all of these models presume practice limitations and/or supervision of practice, even when rehabilitation appears to have been effective. All aim at identifying risk situations so that supervision can be targeted.  A detailed discussion of supervision issues can be found in Schoener et. Al. (1989) which has four chapters devoted to supervision, and Sanderson (1995) has studied the wide variety of signs and symptoms that experienced supervisors feel are connected with misconduct and boundary violations.  Supervision will also be discussed as part of a later discussion in this program on the return to practice.  The most common licensure board error is relenting on such a requirement when the practitioner cannot find anyone willing to truly supervise (and thus be legally liable for) his work.

Retraining may also be prescribed. It is important to note that when a rehabilitation plan involves retraining through, for example, an internship, that in many communities an offending professional undergoing rehabilitation may not be able to find a site for such retraining.  If this is the case it may mean that rehabilitation, while theoretically possible, cannot be accomplished.

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Note that the proposal of a rehabilitation plan does not mean that it is fully carried out or that the professional ever returns to practice. Outcomes include:

  1. Professional refuses the evaluation once he/she sees what it entails;

  2. Professional begins the evaluation but does not complete it;

  3. Professional is evaluated but have a problem that is not able to be “cured”;

  4. Professional is evaluated, but we cannot explain the behavior, and therefore can’t design rehabilitation (in such situations it is legitimate to send them for therapy in hopes of having the situation become clearer, but when more is learned an assessment is still needed);

  5. Professional agrees to rehabilitation, but then goes back and tries to get the requirements changed by the licensure board (or retraining program, or employer);

  6. Professional begins the rehabilitation program but drops out within the first 6 months;

  7. Professional becomes disenchanted with the field during rehabilitation and asks for vocational counseling into another field;

  8. Professional makes all of the progress they are likely to make, but are not sufficiently changed to be a “safe practitioner;”

  9.  Either the “old problems” or newly identified ones are still there -- rehabilitation is not successful.

It is important to make an overall assessment of the success of the rehabilitation effort. In the end the evaluator must put him or herself on the line as regards potential future risks to consumers.  When one is doing the re-evaluation for field re-entry one should be prepared to answer at least two key questions:

  1. To a reasonable degree of psychological certainty, have the goals set for the rehabilitation been attained?

  2. What you have any qualms whatsoever of having your daughter (or wife? Or son?) see this man (or woman) for private counseling?

If you can’t answer these questions with a sense of personal conviction, then the job isn’t done.  If this practitioner is not trustworthy enough to work with your friends and family, he/she shouldn’t be rendering services to others’ families.

If rehabilitation is deemed successful, then the planning for practice re-entry can begin. This is usually done during the later stages of rehabilitation.

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Abel, G., Osborn, C., & Wargerg, B. (1995). Cognitive-behavioral treatment for professional sexual misconduct. Psychiatric Annals. 25,, pp. 106-112.

Abraham, L. (5 Nov.1995). Dr. Smith goes to sexual-rehab school. New York Times Magazine, 5 Nov. 1995, pp. 44-49

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This was adapted from a paper of the same title done for a workshop entitled “Management of Boundary Violations By Professionals,” sponsored by and held at the Menninger Clinic in Topeka, Kansas, 25-26 February 2000.  Nothing in this paper should be construed to be (1) legal advice; (2) professional advice for the handling of a given situation. The exact facts, beliefs, and clinical impressions related to a given circumstance, not to mention statutory or case law, rules, and regulations may affect choices and the weight given to various decision options. Obtaining expert or peer consultation, or a formal evaluation, is advisable when making rehabilitation decisions.


Gary Schoener is a clinical psychologist
Licensed (M.Eq.) in Minnesota. 
He serves as Executive Director, 
Walk-In Counseling Center 
2421 Chicago Avenue S.
Minneapolis, Minnesota 55404
TEL (612) 870-0565,-0574  
FAX (612) 870-4169. 

The Center’s website on the internet is: 

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