OTI Online
Volume 13, 1989

Sexual Malpractice: Therapists Who Seduce their Patients
by Fred Pelka

Judith Daire began therapy in 1971 with a psychiatrist who ended sessions with "a light embrace, and a kiss on the cheek". By 1975 he was kissing her on the lips. By 1976 they were having sex.

Carolyn M. Bates had been seeing her therapist for nine months when he began to "sexualize the relationship". The abuse continued for another 10 months, until Bates terminated the therapy.

The sexual exploitation of patients by physicians is nothing new. The Hippocratic Oath, written more than 2,000 years ago, requires doctors to abstain "from the seduction of females or males, of freemen or slaves" who are patients or living in a patient's household. Presumably, its author would not have included the prohibition if the problem didn't exist.

Neither is the sexual exploitation of clients by psychotherapists anything new. No less a figure than Carl Jung is reputed to have "seduced" at least one of his patients.

"Several states have passed or are considering laws making sexual con- tact between therapist and client a crime, punishable by fine and imprisonment."

It is, however, only recently that the medical establishment has begun to even acknowledge the problem publicly, much less deal with it. The traditionally male-dominated psychiatric and psychological associations, left to police their own, chose in many cases to pretend that the abuse wasn't happening. Medical review boards refused to take the issue seriously. Therapists, fearful of lawsuits or the disapproval of their colleagues, kept quiet even when they knew of instances of abuse. It is no surprise, then, that fewer than five percent of abuse victims ever report their experience to a licensing board or professional association.

"We live in a very patriarchal culture, where the sexual abuse of women and children is highly prevalent," says Dr. Nanette K. Gartrell, associate clinical professor of psychiatry at the University of California in San Francisco. Gartrell, a leader in the movement to address this issue, believes that the sexual exploitation of patients by therapists "is an extension of the general cultural acceptance of sexual abuse of women and children."

In a ground-breaking study published in February 1987, Gartrell and her colleagues concluded that "the best available data indicate that six to 10 percent of psychiatrists have had sexual contact with their patients". Most experts consider this to be a conservative estimate, especially when other types of psychotherapists - psychologists, social workers, chemical dependency counselors, religious and family therapists - are included. Many of the offending therapists have sex with more than one client, some of them abusing hundreds of patients in the course of their professional lives.

Sixty-five percent of the psychiatrists polled in another study said that they had treated at least one client who had been sexually exploited by a previous therapist. The Walk-In Counseling Center in Minneapolis, which has a national reputation for treating victims of therapist abuse, has seen more than 1400 such cases in the last 15 years. Of those cases, roughly 80 percent involved male therapists exploiting female clients.

So widespread is the abuse, and so devastating its consequences, that several states have passed or are considering laws making sexual contact between therapist and client a crime, punishable by fine and imprisonment. Civil codes have also been amended to allow abuse victims easier access to redress through civil lawsuit.

The ethics codes of every psychiatric and psychological association in the country say that sexual contact between client and therapist is unethical. One study indicated that close to 90 percent of clients who have sex with their therapists suffer long-lasting, harmful effects. Drug or alcohol dependent clients sexually exploited by their counselors often lose their sobriety. Many victims end up in psychiatric hospitals for problems directly related to the exploitation.

Nevertheless, throughout most of the country, becoming a "psychotherapist" involves little more than hanging out a shingle or placing an ad in the paper. This means that "counselors" who are not psychiatrists or licensed psychologists or social workers are not bound by any code of ethics.

A former school teacher with a background in engineering, Carolyn Bates is now completing her doctorate in psychology, and has co-authored a book, with Dr. Annette M. Brodsky, called Sex in the Therapy Hour: A Case of Professional Incest, published by Guilford. Bates was 19 years old when the abuse began.

"I went into therapy because I was depressed. I'd left home and a very sheltered family, and I didn't know a lot about how to structure my life. My father had died three years before, and I was still mourning him. I had had my first sexual experience, and felt incredibly guilty about it, coming from a religious background that spoke against that."

Bates trusted "Dr. X", regarding him as a compassionate man with only her best interests at heart.

"One session he asked me if I'd lay on the floor, to relax. About two sessions later he sat down next to me, and rubbed my belly. He told me he was doing 'relaxation exercises'. I wasn't going to question this guy. You'll find that's very common. Patients very rarely question their doctors."

"I felt exposed," says Bates, "laying there with my belly up. I had my arm over my face. He just pulled down my pants and penetrated me."

The abuse continued over the next 10 months of "treatment", as the teenager struggled with her feelings of shame, confusion and betrayal. Unwilling to sacrifice the attention of a man she had come to see as a "father figure", she responded in ways similar to those of incest survivors.

"What I experienced was a lot of confusion, and numbness, not understanding why it was happening, but being caught up in the belief that he was there to help me. His standard line was, until I learned how to relate to him in the office, I would never be able to relate to men outside.

"We had sex probably eight to 10 times, about once a month. I knew we were going to have sex when I came into the office and he locked the door behind us, and closed the drapes. There was one time, right after sex, when he said, "I really felt a breakthrough there."

Judith Daire also went into therapy for depression. Her psychiatrist began treatment by prescribing psychotropic drugs, which Daire believes was a part of his pattern of abuse and manipulation.

"He was considered to be one of the best therapists in Waterbury (Connecticut). Other members of my family had seen him, previously. Very soon after we started therapy he initiated a light embrace, a kiss on the cheek before I left. He always had his door locked. We were always locked in."

Daire's therapist, a married man, promised to divorce his wife, and marry Daire.

"He said he wanted to do everything for me. He didn't want me to go to anyone else for any of my problems."

Daire eventually became so disturbed about what was happening that she attempted suicide.

"I don't think I really wanted to kill myself," she says. "I just wanted to stop the pain."

Victims of therapist abuse, like rape and incest survivors, are often held responsible for their own victimization. Few people recognize the imbalance of power in a therapy/client relationship.

"People have a real hard time with this," says Nancy F. Biele, president of the National Coalition Against Sexual Assault, and director of the Sexual Violence Center in Minneapolis. "They say, 'Look, you've got two consenting adults.' They don't understand how it's possible for this to be called 'abuse'." Dr. Judith L. Herman, assistant clinical professor of psychiatry at Harvard Medical School, likens therapist/client abuse to incest. Dr. Herman, a co-author with Dr. Gartrell of several studies on therapist abuse, is also the author of Father I Daughter Incest, published by Harvard University Press, and considered to be a major work on that issue.

Good therapy, according to Dr. Herman, is dependent upon the client placing trust in her therapist. Clients come to therapy to address their deepest concerns. They often feel vulnerable, confused, frightened. A client may discuss troubling experiences, thoughts and feelings with her therapist that she won't share with anyone else, even her lover or spouse. Consequently, clients often come to view their therapist as an authority figure, almost a surrogate parent, someone whom they respect, even love. These feelings are called "transference".

"And to take advantage of those feelings," says Dr. Herman, "to exploit a patient sexually, is really very similar to a parent sexually exploiting a child." "Transference" also makes it difficult for clients to end the abuse after it has started, and speak out once it has ended. It may be years before the client understands that she has been victimized, and is able to discuss the experience with anyone.

"After the first time," says Biele, "[the victim] feels like she is in collusion with the offender, because she's not saying no. In reality, she can't say no. There's also a fear of hurting the therapist. 'I want this to stop, but I don't want to hurt this guy. He gave me a lot. He has a wife, a family.' Often they don't tell until they've found out that their therapist is also abusing someone else, which also resembles incest."

The violation of trust between therapist and client can be devastating to the victim's self- esteem. An estimated one percent of exploited clients commit suicide. Others, such as Daire, attempt it. Carolyn Bates, though she never acted on her feelings, also felt suicidal after her experience with Dr. X.

"Essentially, it boils down to a sophisticated form of rape, where the coercion is psychological instead of physical," says Dr. Dennis Pearne, a clinical psychologist practicing in Belmont, MA, who has treated several dozen victims of therapist abuse. "Generally, these people end up with a diagnosis of post-traumatic stress disorder, with all the accompanying symptoms: anxiety attacks, nightmares, startle reactions, difficulty venturing outside the home and participating in the outside world."

If nothing else, the introduction of sex into therapy means that the therapy has stopped, that the issues which brought the client into counseling in the first place will never be addressed.

Biele stresses that the abuse also affects a victim's family and loved ones.

"Often, while the exploitation is going on, the victim's relationship with their significant other is deteriorating. And then, when the victim finally spills the beans, the significant other doesn't know what to do. They have a real hard time seeing it as victimization. They're much like other secondary victims, angry and depressed and sad."

The sad fact is that a victim of sexual malpractice may end up losing her therapist, her self-esteem, and sometimes her marriage or love relationship as well.

Minnesota and Wisconsin were the first states in the nation to make the sexual exploitation of clients by therapists a criminal offense. In Minnesota, this legislation came as part of a three year effort by a special task force funded by the state legislature, and coordinated by Barbara E. Sanderson, director of the Minnesota Program for Victims of Sexual Assault. One of the recommendations of the Task Force on Sexual Exploitation by Counselors and Therapists was implemented in 1985, with passage of a law that made sexual contact between therapists and clients, either during therapy or within two years of its termination, a felony offense. A separate bill, passed a year later, made such contact specific grounds for civil lawsuit.

Says Sanderson, "What this does is send a message. It tells the victims, even if they don't file a complaint, that what happened to them is so serious, so bad, that the state has passed a law against it. Victims tell us that alone has been healing."

"It has led to a dramatic improvement," says Gary R. Schoener, a licensed psychologist and executive director of the Walk-In Counseling Center in Minneapolis. Schoener also cites the various workshops, conferences, pamphlets, and articles generated by the Task Force, all with the theme, "It's Never Okay."

"The goal of all this, quite frankly, was to come down on the profession like a ton of bricks, to say to them: 'That's it. No more.' The professional mechanisms are not adequate, and so it has become a social, and therefore a political problem."

Schoener believes that the greatest impact will come as a result of the revision of Minnesota's civil statute, which now holds employers and colleagues of therapists potentially liable for damage caused by sexual exploitation. And so clinics, hospitals and counseling agencies have become much more conscientious when checking the credentials of prospective therapist-employees.

"Just before this law passed," recalls Sanderson, "one of the most reputable agencies in Minnesota hired a therapist who had worked a block from them. They didn't check his references because he was so well known." What wasn't well known, says Sanderson, was that this therapist had been fired "for being sexual with his patients".

Another important feature of the Minnesota package is the mandatory registration of all psychotherapists or counselors. Unlike psychiatrists, and licensed psychologists and social workers, who must conform to professional ethics codes to keep their licenses, unlicensed therapists can operate with relative impunity. Even psychiatrists and licensed therapists who have lost their licenses for ethical reasons can, in many states, continue to practice. By requiring that all therapists be registered, professional associations and state regulatory agencies have greater clout when faced with an unethical practitioner: they can put him out of business by revoking his registration.

Even with mandatory registration and/or licensure, many experts believe that criminal laws such as the one passed in Minnesota are needed to deal with worst case, multiple offenders. Says Biele, "We can slap your hand with ethics. With a felony we can put you in jail."

Dr. X is a good example. Bates and two of his other female clients filed a lawsuit in 1978, which was eventually settled out of court. Several other victims came forward after the suit became public. Another woman filed a complaint in 1984 with Dr. X's state licensing board in Texas, which suspended his license, but allowed him to continue practicing under the supervision of another licensed psychologist. Finally, in 1987, yet another client, this time 17-years-old, called the police and charged Dr. X with sexually assaulting her during therapy. Dr. X pled guilty, and was given a 10-year probated sentence. As a condition of his probation, Dr. X could no longer practice therapy.

After nine years of lawsuits and complaints, it took the threat of a prison term to finally stop Dr. X's abuse. Carolyn Bates returned to therapy a year-and-a-half after terminating with Dr. X.

"I went into therapy with a female therapist, and that was the beginning of recovery. The hardest thing for me was to forgive myself for having been so gullible, for having been so needy. The hardest lesson for me to learn was that the therapist is always responsible."

It was more difficult for Judith Daire to extricate herself from the abuse. After years of medication and psychiatric hospitalizations, she filed suit against her therapist, winning a million dollar court settlement. Her psychiatrist declined to contest the case, alleging that his poor health precluded a court appearance.

Suing a therapist for sexual malpractice is an expensive, difficult and time consuming process. Carolyn Bates was in litigation for more than four years. Even if the suit is successful, many insurance companies refuse to cover claims involving sexual malpractice. Daire, for example, has yet to collect any of her settlement.

"He claims he has no insurance, and no money. Very likely he has hidden his money, but we haven't been able to find it."

The sexual exploitation of clients by psychotherapists doesn't occur in a vacuum. As one respondent to Dr. Gartrell's survey put it, "the American Psychiatric Association should investigate...the deeper issues of psychiatric training and the socialization of men (and doctors) that make this acceptable for some."

"The kind of deeper issues that this person is referring to," says Dr. Herman, "are the pervasive sexism and sexually exploitative attitudes of the wider society. It's simply an exaggeration of socially accepted norms: that a male should be in a position of greater dominance and power, and a female should be subordinate."

Dr. Gartrell and Dr. Herman both point to the lack of sexual ethics training at medical schools and counselor training programs as a factor contributing to the incidence of sexual malpractice. Sexual "counter transference" - the erotic feelings a therapist might have for a client - is rarely discussed in therapy training or supervision.

Even more disturbing, studies by Gartrell, Herman and others, demonstrate that sexual boundaries are also violated in therapist training programs and medical schools. One study, by Los Angeles psychologist Kenneth Pope, found that one in four women with doctorates in psychology had had sex with a professor or supervisor.

"The system is contaminated from above," says Estelle Disch, clinical associate with Tapestry, a feminist counseling and education center in Cambridge, MA who runs support groups for victims of sexual malpractice."The teachers are sleeping with their students, the supervisors are sleeping with their supervises. They're not exactly great role models."

Even so, Gartrell and others are pleased with the progress made in the past two years. They point to the formation by the American Psychiatric Association (APA) of a working group on sexual malpractice, which has produced several videos and other educational materials on the subject. Efforts are underway to strengthen the ethics codes of the various psychotherapy associations. Medical schools and training programs are beginning to include discussions of sexual abuse in their ethics courses. And legislation criminalizing therapist abuse, and calling for mandatory registration of psychotherapists, is being considered in states all across the country.

This is in marked contrast to the situation a few years ago, when the APA refused to sponsor Gartrell's study on the incidence of sexual malpractice, and funding for the project had to be solicited from sympathetic therapists.

"We have a long way to go in most states," says Gartrell, "to get anywhere near what has been accomplished in Minnesota." She calls for a national effort, along the lines of the Minnesota Task Force, to produce a national response to the problem.

In the meantime, therapy clients, particularly women, need to be aware that this sort of exploitation occurs. Carolyn Bates, soon to be a practicing therapist, stresses the benefits of good therapy, as opposed to the risks of abuse.

"It's important to recognize that the vast majority of mental health professionals are good and caring and ethical people, and want to address this issue." Bates emphasizes that clients need to be aware of their rights, and willing to ask questions when they think something is wrong. Clients have to be educated, so that those who are sexually exploited know they're not alone, and are not blamed for their victimization.

Says Dr. Pearne, "Anyone who enters a psychotherapeutic relationship in an open and trusting manner, which is the healthiest way to enter that relationship, is vulnerable to abuse."

The Minnesota Task Force has recently published It's Never Okay, a collection of 40 articles on every aspect of sexual exploitation of clients by therapists. For more information, write to The Task Force on Sexual Exploitation by Counselors and Therapists, Minnesota Program for Victims of Sexual Assault, Minnesota Dept. of Corrections, 300Bigelow Building, 450 North Syndicate Street, St. Paul, Minnesota, 55104, or call (612) 642-0256.

WARNING SIGNS

Barbara E. Sanderson, coordinator of the Minnesota Task Force on Sexual Exploitation by Counselors and Therapists, lists these warning signs.

If the therapist:

• singles out a client as "special" or "favorite";
• suggests special arrangements, such as meetings after office hours, or at the home of the client or therapist, or waives fees contrary to normal office procedure;
• focuses on sex (unless the client has a specific sexual problem), tells sexual jokes, or asks intimate questions unrelated to the therapy, or "ogles" the client, undresses, or suggests that the client undress during therapy;
• shares personal information about himself or herself, talking about his own problems rather than the client's;
• uses alcohol or drugs during therapy, or suggests that the client use alcohol or nonprescription drugs; • asks the client to keep secrets about the therapy;
• is uncomfortable answering questions about his credentials, or where the therapy is going;
• suggests unusual financial or business arrangements with the client;
• If a therapist asks for a date, or suggests or initiates sexual activity, such as kissing, petting, or intercourse, it is without doubt time to find a new therapist. Likewise, it is unethical for a therapist to end therapy in order to start a romantic or sexual relationship with a client.


Fred Pelka is a freelance writer living and working in Boston, MA. His articles have appeared in Boston Magazine, Christianity and Crisis, Hospital News, The Disability Rag, Peacework, and elsewhere. He is also co-founder and coordinator of Boston / Cambridge Men Against Sexual Assault.

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