‘Neutralising the patient’: therapists’ accounts of sexual boundary violations

‘Neutralising the patient’: therapists’ accounts of sexual boundary violations Nick McNulty, Fiona Warren, Jane Ogden SPR 2010 Conference

Sexual attraction to clients SPR 2010 Conference

Therapist-client sex: survey data SPR 2010 Conference

Therapist profile • Male, 40s (Pope, 1990) • High status, education & professional training (Pope et al, 1979) • Marital difficulties (Butler & Zelen, 1977) • History of boundary violating relationships (Jackson & Nuttall, 2001; Lamb & Catanzaro, 1998) • Permissive attitude to boundary violations (Garrett & Davis, 1998) • But no agreed predictive characteristics(Halter et al., 2007) SPR 2010 Conference

The acts Sexual boundary violations Therapist client sex (TCS) Sexualised dual relationships Therapist sexual abuse The participants Therapists Violators Offenders Therapist perpetrators Getting the language right SPR 2010 Conference

How & why does it happen? • Behavioural pattern – • ‘slippery slope’ (Simon, 1995) • Psychodynamic typologies • ‘lovesickness’ • ‘masochistic surrender’ • predatory therapists (Gabbard, 1992) SPR 2010 Conference

Limitations of models • No role for conscious processes • No theoretical basis for protective factors • boundary violations in professional training • trusting supervisory relationship • professional rules • No evidence that personal therapy was protective SPR 2010 Conference

My study • Interviews with disciplined psychologists • Interpretative Phenomenological Analysis (IPA) • ‘double hermeneutic’ • ‘defended’ subject • Direct contact with potential participants • real world value of study • value & appropriateness of method • Participant benefit in direct contact studies SPR 2010 Conference

Participants • 2M, 1F • Psychologist, counsellor, psychiatrist • 1 relationship with current patient, 2 with former • 2 again working in MH services • 1 face-to-face interview, 2 over phone, 67 minutes average length SPR 2010 Conference

Summary of findings • neutralisation of the client’s status as a mental health patient • minimising their mental health problems • emphasising the conventionality of the relationship • relationship not revealed to supervisors. • therapist’s identity- victim or a perpetrator. SPR 2010 Conference

Client’s presenting problems are slight and amenable to treatment • client didn’t really need medication, she needed a bit of psychotherapy. • [the client] made, you know, a complete recovery, gained complete relief from what it was she’d been going through. SPR 2010 Conference

Course of relationship is conventional and consensual • That’s what pushed it for me, meeting his partner and meeting his children and you know being part of a normal ritual, having a cup of tea with some people. • We became engaged …. Decided to set up home together. All of this was properly considered. We went through lawyers, you know, all the rest of it. We bought, we bought a property together and we started living together. SPR 2010 Conference

Relationship of equals • As I say, she was a trained therapist herself • The patient was the same age as me, so it wasn’t, it wasn’t as if you know she was a very young person SPR 2010 Conference

Sex and therapist’s needs are not important • We had some kind of sexual relationship at a certain point but that certainly wasn’t important to me. • …my sort of marriage was breaking up basically. So I guess putting those two things together basically that’s probably why I made contact with her. SPR 2010 Conference

Origins of relationship are not discussed • I did discuss it with one particular colleague but somewhat indirectly so she, she didn’t know I was talking about an ex-patient basically. So I suppose, no, so I wasn’t fully open about it. • I’d disclosed it to my employer because one of the difficulties was, that she may very well have needed hospitalising. SPR 2010 Conference

Client is mad or bad • She’d also attacked me physically. Totally out of character. There was far more increased aggression. Multiple calls to my ex-employer. To the police. • He was very clever. Oh yes, incredible. And that’s of course what my ex had been as well, very manipulative. SPR 2010 Conference

Avoid relationships with clients • Never go anywhere near an ex-client. • In terms of more psychological or a psychotherapeutic things I think the distinction largely disappears and the safest recourse I suppose is to say that one should never have a relationship with an ex-patient… SPR 2010 Conference

Therapist – hero, victim, perpetrator • Her HONOS scores, what do you call it, the CORE scores, the self-report measure, everything, she was well below the clinical cut-off point. Normality had been achieved. • So I was sort of shocked, partly that I misjudged her personality so much and that she obviously had much larger problems than I anticipated. SPR 2010 Conference

…you lose your professional network, your social network shrinks, and you become a salesman because nobody else will employ you, because I was dismissed from the NHS. SPR 2010 Conference

So how do I look at my boundary violations? I was ill, I was very ill. I could function, without pressure I could function, but he put a lot of pressure on me and that’s what I couldn’t, I wasn’t strong enough to resist that. SPR 2010 Conference

The only consequence for her…I’ve got absolutely no idea how or if she has benefited. I can only assume that she will have had some money at the end of the day. • The whole experience has been more damaging for me than for him…For him? No. He’s back with his partner. His partner’s a bit wiser. But for him, no. SPR 2010 Conference

I do regret what I’ve done. Obviously, it’s easy to regret things when you’ve had enormous negative impact on one’s life and standing and everything basically… So I suppose I do have quite a few regrets and I wished it had been different but I can only say that in hindsight really. SPR 2010 Conference

Implications • Implicit theories? • Denial of harm • Permissiveness of non-sexual boundary violations • Minimising power differentials • Enabling cognitions or post-hoc rationalisations? • Material for education and training • Central role of supervision • Supervisee and supervisor discomfort SPR 2010 Conference

Reflections • Ebb & flow of my sympathies • Awareness of own vulnerability • Demonizing vs collusion • Researcher ‘neutrality’ SPR 2010 Conference

Chris: I dunno, what do you want to know about it [the relationship] really? • I: I guess I’m just interested in the course of it really. You know, you can tell me what you want to about it really. I’m not particularly interested in poking into the details but just to, you know, to understand the trajectory. SPR 2010 Conference

Selected References • Celenza, A. & Gabbard, G. (2003). Analysts who commit sexual boundary violations: A lost cause? Journal of the American Psychoanalytic Association, 51(2), 617-636. • Feiner, A. (1977). Discussion (therapeutic function of hate in the countertransference). Contemporary Psychoanalysis, 13, 461-468. • Garrett, T. & Davis, J. (1998). The prevalence of sexual contact between British clinical psychologists and their patients. Clinical Psychology and Psychotherapy, 5, 253-263.Giovaziolas, & Davis (2001). • Giovazolias , T. & Davis, P. (2001) How common is sexual attraction towards clients? The experiences of sexual attraction of counselling psychologists towards their clients and its impact on the therapeutic process. Counselling Psychology Quarterly, 14, 281-286. • Groves, J. (1978). Taking care of the hateful patient. New England Journal of Medicine, 298, 883-887. • Halter, M, Brown, H & Stone, J. (2007). Sexual Boundary Violations by Health Employees: An Overview of the Published Empirical Literature. London: Council for Healthcare Regulatory Excellence and Department of Health. • Nickell, N., Hecker, L., Ray, R. & Bercik, J. (1995). Marriage and family therapists’ sexual attraction to clients: an exploratory study. The American Journal of Family Therapy, 23, 315-327. • Pope, K., Keith-Spiegel, P. & Tabachnick, B. (1986). Sexual attraction to clients: The human therapist and the (sometimes) inhuman training system. American Psychologist, 41, 147-158. • Pope, K. & Tabachnick, B. (1993) Therapists’ anger, hate, fear and sexual feelings: National survey of therapist responses, client characteristics, critical events, formal complaints and training. Professional Psychology: Research and Practice, 24(2), 142-152. • Simon, R. (1995). The natural history of therapist sexual misconduct: identification and prevention. Psychiatric Annals, 25, 90-94. SPR 2010 Conference

‘Neutralising the patient’: therapists’ accounts of sexual boundary violations