Saturday, November 27, 2010

Article Review: Obstacles to the dynamic understanding of therapist-patient sexual relations

I reviewed this article for my sexuality and sex therapy class. Gutheil & Gabbard (1992) look at the complexity of the therapist-client sexual relationship from a psychodynamic perspective - while the therapist is always violating ethical codes in having such a relationship, it's not nearly so cut and dried as people tend to view it.

When I was an undergrad way back in the day, my Psych 101 professor (who also had a private practice) was well-known in the community for sleeping with his attractive female clients. This was 1987 - there probably was not a law against it, although I'm sure even then it was an ethics violation. But no one ever reported him that I knew about. He was the guy most people think about when they hear of a therapist sleeping with a client - and while that is the majority of cases, it is certainly not ALL of them.
Full citation:
Gutheil, T., & Gabbard, G. (1992). Obstacles to the dynamic understanding of therapist-patient sexual relations. American Journal of Psychotherapy, 46(4), 515-525. Retrieved from MEDLINE with Full Text database.
Here is the introduction to the paper, just so it is clear that I nor the authors are condoning sexual misconduct and sexual relationships between therapist and client. [Interestingly, I did not feel the need to do this for class, but I do here in this public space.]
Therapist-patient sexual misconduct represents a serious problem in clinical, legal, and ethical terms. Sexual relations of this nature are harmful to patients, destructive to the work of therapy, and damaging to the profession itself. Such behavior has become one of the chief sources of malpractice litigation against psychiatrists in recent years, and several states have now criminalized therapist-patient sexual misconduct.

Given the gravity of the issue and the need for a more comprehensive understanding of the dynamics that lead to such tragic distortions of the therapeutic relationship, it is alarming that the topic has become—in some quarters under some circumstances—undiscussable in rational and temperate discourse for reasons that include political and policy concerns. This difficulty in discussion, which constitutes the main topic of this communication, appears to relate to a number of factors, including a widespread longing for simplicity of world view, a longing that prompts resistance to a more complex (and hence, a more realistic) analysis. The unfortunate effect of this undiscussability, however, is the creation of an empirical and conceptual blind spot in the precise area where we desperately need to increase and expand our understanding.

The problems we are identifying were nicely captured in a recent Newsweek cover story entitled "Thought Police" (12/24/90). The essence of this article was that a number of current problems cannot be addressed in public discourse because they are seen as "politically incorrect" and thus unwelcome to their respective audiences. Strikingly, this form of oppression was highlighted in the story as occurring on academic campuses, traditionally arenas of freedom for unfettered discourse.

In the case of therapist-patient sexual misconduct, the "politically correct" version of the phenomenon is that a psychopathic male therapist preys on a victimized female patient, who herself plays no role in eliciting such behavior, and who is always severely traumatized by the experience. To attempt to examine the psychodynamics of the therapist, the patient, or the interaction between them may be viewed as either "blaming the victim" or overly sympathizing with the offender. In other words, it is not politically correct in some venues to approach cases of sexual misconduct as complex interactions deserving detailed and systematic psychodynamic understanding.

As an example of the kind of interference with empirical scientific inquiry with which we are concerned, one of us was recently presenting a paper to a large workshop audience on the subject of borderline personality disorder. In passing it was noted that a study of sexual transgressions by mental health professionals in an inpatient setting revealed that the patients involved were predominantly borderline. The presentation was immediately interrupted by a woman in the audience who said that therapist-patient sexual relations were caused by predatory male therapists and that it was therefore inappropriate to focus on the patients involved. The presenter explained that he was in no way "blaming" the patients but simply reporting the results of a study.

Another audience member rose to her feet and said that therapist-patient sex was always the fault of the therapist. The presenter agreed that only the therapist could be held responsible for the boundary violations under discussion. He went on to say, however, that studying the transference-countertransference dynamics of such interactions was extremely useful in that it provided a basis for educating professionals about warning signals and the need to seek consultation when such signals arise. A third audience member suggested that education was of no value and instead proposed that criminal penalties analogous to those for rape were the only answer.

In a recent article published by one of us,' the common countertransference responses evoked by borderline patients were discussed in some detail. Included among these countertransference responses was the tendency of some therapists to step outside their usual professional role in an effort to accommodate the intense demands and longings of patients with borderline psychopathology. In response to this article, a series of letters accused the author of "blaming the victim" even by examining these dynamics. One such letter stated:
Although Dr. Gutheil asserts [in the article] that he is not "blaming the victim," it is difficult to read his article without a strong sense that the patient's, not the therapist's problems give rise to sexual exploitation by the therapist . . . [Other comments] certainly suggest it is the patient's rather than the therapist's behavior and dynamics that bear scrutiny [in such cases] . [emphasis added]
Note the simplistic "zero-sum game" conceptualization, as though either member of the dyad must be the sole source of the problem. The possibility that both could be contributing to the situation was not even considered. Note also the implication that even scrutiny of dynamics itself may be "aimed" at one or the other party, but not both, in fine disregard of the inherently dyadic nature of therapy; indeed, one might infer, perhaps, that the letter writers believe that only the therapist's dynamics are suitable for scrutiny.
Hopefully, that establishes a sense of what these authors sought to do in this article. My brief summary follows:

Sexual relationships between therapist and clients have become the primary source of malpractice litigation against therapists in recent years. Many states have criminalized sexual misconduct on the part of mental health professionals.

The way the situation is generally viewed - the “politically correct” version - is that a psychopathic male therapist victimizes a wounded and vulnerable female patient who plays no role in creating the seduction. The challenge becomes finding a way into the situation that is honest and that does not look like “blaming the victim” or sympathizing with the offender. There must be a way to deal with the situation as the complex psychodynamic relationship that it is.

Several studies have found that the female patient in these relationships is often suffering from "borderline personality disorder" - I diagnosis that I personally do not support. Reports of these studies elicited accusations of “blaming the victim.”

The authors propose three axioms:
  1. Only the therapist has a professional code to violate, so only the therapist is liable or criminal – is blameworthy. The patient has no ethical code and therefore cannot be blameworthy.
  2. Both the therapist and the client are (in general) competent adults and are accountable for their behaviors, as are all adults. By Axiom 1, the victim is not being blamed. This is only intended to state that a complex interaction of transference-countertransference is at work.
  3. Only a careful and candid examination (without political correctness issues) of the psychodynamic issues can fairly explain a sexual relationship on this type. None of which means it will be easy, comfortable, or reassuring – only that doing so is in the best interests of the practice, the patients, and the public.
The usual obstacles to a careful examination of the situation:
  • All or nothing thinking (black and white morality) - people have a tendency to see these relationships as purely wrong on the part of the therapist, which is only a partial truth. The situation is often, though not always, more complex than it seems on the surface.
  • Gender bias (against males) – a lot of time is spent on this, demonstrating that yes, men are most likely to abuse, but that female-female “boundary violations” happen quite often and are not reported. Further, to even talk about female therapists as violators is often seen to be deflecting the issue away from men, not as presenting a whole picture.
Three primary truths (from the research, one of these is generally true):
  • The therapist was predatory.
  • The therapist felt pursued and coerced into a sexual relationship.
  • The therapist felt the sexual relationship was “true love.”
Three conclusions the authors reach based on the available research:
  1. Objective examinations of sensitive issues such as this do not always yield the results people most want to hear or feel comfortable with – outcomes may not fit “our favorite worldview.”
  2. The “politically correct” model therapist-patient misconduct is often true, but it is not accurate in all cases. Failing to objectively analyze each case because of ideological biases is wrong.
  3. The transference-countertransference developments (of which sexual misconduct is one type) in a therapeutic relationship are, by definition, repetitions of past relationships – they must be viewed in terms of the complexity inherent in all human relationships.
Finally, the authors offer this summary of their research on this topic:
Several dynamic resistances appear to interfere with rational and empirically based discourse about therapist-patient sexual misconduct. These resistances include the lure of reductionism and a longing for simplicity; wishes for "political correctness"; gender bias; and confusion about the nature of the trauma in sexual misconduct.

We conclude that (1) empirical study may produce unpleasant results; (2) "politically incorrect" models of misconduct merit study with care equal to "politically correct" ones; and (3) those reenactments we call transference-countertransference should be viewed in all their human complexity. Only then will our increased understanding of misconduct offer hope of prevention.

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