Behind Closed Doors: Sex Therapists

Read about what happens when therapists cross the line.

By Carl Sherman, published on May 01, 1993 - last reviewed on August 30, 2004

Aired and analyzed, these feelings, including erotic ones, can be a potent force for growth and healing change--the intimate relationship with the therapist often makes it possible to come to terms with long-hidden love, shame, anger, and fear. But it is the therapist's highest responsibility to make sure it all remains talk, not action--to keep therapy a safe place where the deepest feelings can be bared without getting out of control.

For this reason, any responsible therapist will scrupulously maintain the businesslike boundaries that separate personal from professional: making sure doctor and patient stay in their respective chairs during the therapy hour and avoiding contact outside the office. Responsible therapists keep their own problems and private life out of the therapeutic relationship.

Not all honor and protect those boundaries, however. A calculating, predatory therapist may violate them deliberately, encouraging a vulnerable patient to act on the strong emotions brought up from the past. He may tell a patient who is confused by the rush of unfamiliar feelings that sex is a legitimate treatment, dismissing her fears and attempts to repel his advances as "resistance" to therapeutic change. A substantial number of sexually exploiting therapists fall into this category, says Gabbard. Many are sociopaths incapable of true remorse or empathy and who may leave a trail of 20, 50, or more victims.

But the story isn't always such black and white melodrama. Basically healthy, moral therapists are human, too; in the intimacy of therapy, a patient's powerful needs and affections may call forth intense "countertransference" emotions, awakening strong feelings from the therapist's own past. To feel adored and idealized can be heady stuff even to a professional, particularly one who may be depressed, lonely, in the midst of a personal crisis such as divorce, or just feeling unappreciated at home. Under such circumstances, the best intentions and scruples maybe swept away.

Perhaps half of those who engage in sex with patients are what Gabbard calls "lovesick" therapists: they sincerely believe that what's happening to them is true love, not transference. They believe it is a once-in-a-lifetime miracle that obeys no laws but its own, and that they and their patient are "soulmates" to whom ordinary rules do not apply.

To know where transference and countertransference feelings are coming from and how to avoid acting on them should be basic training for all therapists, but in fact it's largely a hit-or-miss affair. Residency training in psychiatry and graduate programs in psychology must include some ethics instruction, but there's no strict requirement that sex issues be treated explicitly or at length. "We've surveyed the field, and there's a range, from excellent to cursory, in teaching about boundary violations and sexual misconduct," says James H. Scully, M.D., deputy medical director of the American Psychiatric Association.

No matter how thorough or lax their education, every psychotherapist in practice today should surely know this: sex between therapist and patient is ethically wrong, whatever the scenario. Always. Every professional psychotherapy organization--the American Psychological Association, the American Psychiatric Association, the National Assocation of Social Workers, the American Association for Marriage and Family Therapy--is in unambiguous agreement on that point.

But why, if the patient is willing? Because the feelings unleashed in therapy are so strong, "consent" may have no more meaning than it would with an underaged sex partner. Even when the patient initiates sex--as happens in an estimated 14-25 percent of cases--it is still the therapist who is ethically, and increasingly legally, obligated to make sure it doesn't happen.

"A patient can be seductive, threaten to kill herself if she doesn't get what she wants, or take off her clothes in the session. She has no code to uphold, no standard of behavior to violate," says Thomas Gutheil, M.D., professor of psychiatry at Harvard Medical School. Still, if sex invades therapy, "only the professional can be to blame."

A MALE PRACTICE?

In the majority of cases, the therapist is male and the exploited patient female--a reflection, some say, of power imbalance in a society where men are used to getting what they want and women are conditioned to giving in to them. And so to many, therapy abuse has been reduced to a burning symbol of male oppression.

Some believe, however, this focus has gone too far, transforming a complex issue into a gender-war morality play in which a psychopathic male therapist invariably preys on a passive female patient who has done nothing to elicit such behavior and is always severely traumatized. "Any variation from this rigid formula feels, to some people, as if you excuse the therapist or the sex, or you blame the victim," says Gutheil. In one extreme example, a speaker who chose to illustrate her lecture on sexual misconduct with a case involving a female therapist and male patient was formally accused of sexual harassment by two members of her audience.