Sexual Feelings and Behaviors in the Psychotherapy Relationship: An Ethics Perspective Jeffrey E. Barnett Loyola University Maryland Sexual intimacies with clients are inappropriate behaviors under all circumstances. Yet, psychologists who adhere to rigid rules about boundaries and multiple relationships in an ill-guided effort to avoid such occurrences may find that they actually harm clients by acting in ways that are inconsistent with clients’ treatment needs and goals. Boundaries and multiple relationships are discussed and strategies for negotiating them effectively are presented. A thoughtful and deliberative process is described for responding to the inevitable feelings of attraction toward clients that at times arise, and steps for addressing psychotherapists’ vulnerabilities are presented. Ethics principles and standards as well as decision-making considerations are presented so that psychologists will be better prepared for C 2013 Wiley Periodicals, Inc. J. Clin. Psychol. addressing these important issues in psychotherapy. 70:170–181, 2014. Keywords: boundaries; multiple relationships; ethics; attraction; sexual intimacies
Each of the mental health professions makes very clear in their codes of ethics the importance of establishing and maintaining clear boundaries between clinicians and those they serve (e.g., clients, supervisees, and students) to prevent actions and behaviors that may lead to exploitation of, or harm to, these individuals. The Ethical Principles of Psychologists and Code of Conduct (American Psychological Association [APA] Ethics Code; APA, 2010) includes standards that forbid sexual intimacies with current psychotherapy clients and patients (Standard 10.05), sexual intimacies with relatives or significant others of current psychotherapy clients and patients (Standard 10.06), and psychotherapy with former sexual partners (Standard 10.07). Additionally, Standard 10.08, Sexual Intimacies With Former Therapy Clients/Patients, forbids psychologists from engaging in sexually intimate relationships with former clients for a minimum of 2 years from the date of last professional contact and even then, only “in the most unusual circumstances” (p. 13). This standard then goes on to specify seven factors that psychologists must consider when deciding if such an activity will be appropriate and meet this “unusual circumstance” criterion. Additional standards in the APA Ethics Code (APA, 2010) apply this general prohibition against sexually intimate relationships to all those psychologists interact with in their professional roles. For example, Standard 7.07, Sexual Relationships With Students and Supervisees, forbids psychologists from engaging in sexually intimate relationships with any student or supervisee “over whom psychologists have or are likely to have evaluative authority” (p. 10). It is made clear in the APA Ethics Code (APA, 2010) that sexually intimate relationships with clients and others that psychologists interact with in their professional roles should be avoided. Yet not all multiple relationships with clients and others are viewed as inappropriate or unethical. In fact, Standard 3.05, Multiple Relationships, articulates that: A psychologist refrains from entering into a multiple relationship if the multiple relationship could reasonably be expected to impair the psychologist’s objectivity,
Please address correspondence to: Jeffrey E. Barnett, Department of Psychology, Loyola University Maryland, 4501 N. Charles Street, Baltimore, MD 21210. E-mail: [email protected] C 2013 Wiley Periodicals, Inc. JOURNAL OF CLINICAL PSYCHOLOGY: IN SESSION, Vol. 70(2), 170–181 (2014) Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp). DOI: 10.1002/jclp.22068
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competence or effectiveness in performing his or her functions as a psychologist, or otherwise risks exploitation or harm to the person with whom the professional relationship exists. (p. 6) This standard is consistent with the overarching requirement psychologists have to avoid harming others. Standard 3.04, Avoiding Harm, states: “Psychologists take reasonable steps to avoid harming their clients/patients, students, supervisees, research participants, organizational clients, and others with whom they work, and to minimize harm where it is foreseeable and unavoidable” (p. 6). Additionally, Standard 3.06, Conflict of Interest, requires psychologists to avoid all relationships that “could reasonably be expected to (1) impair their objectivity, competence, or effectiveness in performing their functions as psychologists or (2) expose the (client) to harm or exploitation” (p. 6). Taken together, these ethics code standards articulate the profession of psychology’s current thinking on sexually intimate behaviors and relationships with those psychologists interact with professionally. Yet despite these prohibitions, such behaviors occur, estimated to be engaged in by up to 9.4% of male psychotherapists and by up to 2.5% of female psychotherapists (Pope, Keith-Spiegel, & Tabachnick, 2006), resulting in significant harm to individuals who had entrusted psychologists with their welfare, along with harm to the reputation of the profession of psychology, and possibly even to the public in general who may avoid seeking needed mental health treatment services as a result of a lack of trust of psychologists in general. Thus, prohibitions in the profession’s ethics code are not sufficient for preventing these harmful behaviors from occurring. With greater understanding of the underlying causes of these behaviors, it is hoped that steps can be taken to minimize the likelihood of their occurrence in the future, for the benefit of all involved.
The Psychotherapy Relationship and Professional Obligations Psychologists provide professional services to clients in the context of relationships that are built upon trust. Clients regularly share their most closely held secrets, fears, insecurities, and vulnerabilities with their psychologist, things they may never have shared with another person, in the hope of receiving assistance that will result in the resolution of underlying conflicts, issues, and distress (Barnett, Lazarus, Vasquez, Moorehead-Slaughter, & Johnson, 2007). This creates dependence on the psychologist and vulnerability for the client. Clients rely on and trust their psychologist to utilize the information shared solely for the purpose of assisting the client to achieve his or her treatment goals, and not to satisfy the psychologist’s personal needs or interests. This focus on trust and psychologists’ obligations to their clients is seen in the aspirational General Principle B: Fidelity and Responsibility, of the APA Ethics Code (APA, 2010), which states: Psychologists establish relationships of trust with those with whom they work. They are aware of their professional and scientific responsibilities to society and to the specific communities in which they work. Psychologists uphold professional standards of conduct, clarify their professional roles and obligations, accept appropriate responsibility for their behavior and seek to manage conflicts of interest that could lead to exploitation or harm. (p. 3) Thus, it is essential that psychologists are mindful of their obligations to clients, to include avoiding all actions and behaviors that hold the potential to be harmful to, or exploitative of, clients. As Principle B, above, explains, psychologists also have responsibilities to society at large; in addition to not taking advantage of clients’ dependence and trust, they must not engage in actions that will violate the public’s trust of the profession in general.
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Boundaries and Multiple Relationships Boundaries By need and design, the psychotherapy relationship is different from all other relationships that both client and psychotherapist enter into. As such, this relationship is guided by a set of boundaries that help clarify and define appropriate behaviors and expectations. Boundaries are defined by Knapp and VandeCreek (2012) as the “rules of the professional relationship that set it apart from other relationships” and that “clarify which behaviors are appropriate and inappropriate in psychotherapy” (p. 87). The presence of boundaries in the psychotherapy relationship helps to promote a safe and trusting environment in which clients may receive needed treatment services without risking exploitation or harm. Boundaries “provide a foundation for this relationship by fostering a sense of safety and the belief that the clinician will always act in the client’s best interest” (Smith & Fitzpatrick, 1995, p. 500). A number of different boundaries exist that typically are relevant to the psychotherapy relationship. These include location, time, interpersonal space, self-disclosure, touch, and gifts. Boundaries may be avoided, crossed, or violated. As will be seen, there is a certain amount of flexibility appropriate for how psychologists address and manage boundaries, and a decisionmaking process is often needed to guide psychologists in how to best do so in some situations. But boundaries cannot be overlooked or ignored and must be thoughtfully considered in all psychotherapy relationships. To avoid a boundary means to not engage in the behavior in question. As an example, one can have a rule that prohibits ever engaging in any form of touch with clients, such as on an inpatient unit where any use of touch might possibly be misconstrued by a patient or when providing psychotherapy to a client with a history of sexual trauma for whom a casual hand on the shoulder might be traumatizing. A boundary crossing involves transgressing the boundary, but is not considered to be inappropriate, unwelcomed, or harmful, such as shaking a client’s extended hand upon meeting him or her for the first time or hugging a client who is grieving if welcomed by that client. A boundary violation, by definition, involves transgressing a boundary in a manner that is considered to hold a significant potential for exploitation or harm, that violates accepted professional standards, or that is unwelcomed (Smith & Fitzpatrick, 1995). Examples of boundary violations may include inappropriate or sexual touch or other intimate or unwelcomed physical contact. Each of the above-mentioned boundaries may be avoided, crossed, or violated. Certainly, what it means to avoid a boundary is likely to be widely agreed upon (e.g., never engaging in any touch with clients and never accepting a gift from a client). While there are some widely accepted standards with regard to whether a particular behavior is viewed as a boundary crossing or boundary violation (e.g. what constitutes an inappropriate self-disclosure and sexually intimate physical contact with a client), in many situations the use of a deliberative decision-making process is needed to help determine the appropriateness of one’s behaviors. Factors to consider that help determine if a particular behavior would constitute a boundary crossing or a boundary violation are as follows.
The client’s presenting problems, mental health history, and the nature of the treatment being provided. What constitutes a boundary crossing versus a boundary violation may be impacted by the nature of the client’s presenting problems and the length and intensity of the treatment being provided. These factors may impact the client’s level of dependence on the psychologist as well as the client’s vulnerability to the psychologist’s influence. For example, a client who presents with dependence issues, a need to please authority figures, and emotional vulnerability may be at greater risk of exploitation or harm and the psychologist may therefore need to exercise greater caution when considering boundaries.
The psychologist’s intent. It is vital that decisions made about boundaries be based on a thoughtful appraisal of the client’s best interests and treatment needs. Boundary decisions should never be made based on the gratification of the psychologist’s personal needs. Such
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actions would be inimical to psychologists’ responsibilities to only act in the client’s best interests.
If the client welcomes the action or not. If a client does not welcome an action or behavior, then, by definition, it is a boundary violation because it is violating the client’s comfort or desires and should not be engaged in. But even if a client welcomes an action on the psychologist’s part, this does not mean that the behavior is a boundary crossing. As is addressed above, clients may have emotional vulnerabilities, dependence on the psychologist’s view of them, and an inability to exercise autonomous decision making. Psychologists must engage in decision making that places paramount emphasis on the client’s needs and best interests. The psychologist’s theoretical orientation. Psychologist theoretical orientation factors may also impact views of boundaries. For example, the use of self-disclosure and touch may be more consistent with the perspectives held by humanistic psychotherapists as opposed to psychoanalytic or psychodynamic psychotherapists. Cognitive behavioral psychotherapists may view providing treatment in a client’s home differently than psychodynamic psychotherapists (e.g., to treat agoraphobia). Diversity issues and prevailing community standards. Psychologists’ actions and behaviors may be viewed quite differently by individuals from culturally diverse groups and backgrounds. Attention to prevailing community standards is important since normative behaviors may vary by group. Some cultural groups may give gifts as a gesture of appreciation for assistance provided and to refuse the gift may be interpreted as an insult. Some groups may kiss others on each cheek upon greeting them each time they meet. Failure to attend to individual and group differences may result in violating boundaries and potentially harming the psychotherapy relationship unintentionally. Multiple Relationships Multiple relationships are those situations in which a psychologist is engaged in one or more additional relationships with a client in addition to the treatment relationship. Multiple relationships may be sexual or nonsexual. Nonsexual multiple relationships may include social, familial, business or financial relationships, and possibly others. Multiple relationships are distinguished from incidental contacts. Incidental contacts are situations in which the psychologist and client have an interaction in another setting that is unplanned and very brief. Examples may include noticing that the psychologist and client are attending the same concert or community event, being members of the same organization, or briefly crossing paths in the community. As the APA Ethics Code (APA, 2010) clearly states in Standard 3.05, Multiple Relationships, not all multiple relationships are to be avoided or are to be considered inappropriate. In fact, this standard clarifies that only those multiple relationships that are likely to lead to exploitation or harm of the client and/or that are likely to adversely impact the psychologist’s objectivity and judgment should be avoided. Multiple relationships that do not meet these criteria do not need to be avoided and, in some circumstances, are appropriate, enriching, and often even essential for meeting the client’s best interests (Lazarus & Zur, 2002). Multiple relationships may also involve sexually intimate behaviors and may occur concurrently such as entering into a romantic or sexual relationship with a current client or an individual closely related to or associated with the client, or sequentially such as accepting into treatment a former lover or entering into an intimate relationship with a former client. As has been reviewed, the APA Ethics Code (APA, 2010) addresses each of these circumstances in enforceable standards that prohibit the first two under all circumstances and allows only for the later type of multiple relationships in certain rare circumstances. As will be reviewed below and described in detail by Sonne (2013), each of these types of multiple relationships brings with them significant potential for exploitation, abuse of trust and dependence, and inevitable harm to the client or former client.
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A Historical Context The early literature on sexually intimate multiple relationships viewed them from a psychodynamic perspective that focused on mismanagement of the transference relationship by the psychotherapist (Gutheil & Gabbard, 1993). Additionally, it was noted that sexually intimate multiple relationships between psychotherapists and their clients typically occurred after a series of increasingly intrusive and inappropriate behaviors over time, a process termed “the slippery slope” (Gabbard, 1989). From a boundaries perspective, it was hypothesized that psychotherapists move from boundary crossings to boundary violations, each increasingly placing the client’s welfare at risk. Because of the fact that sexually intimate multiple relationships with clients, which are always harmful and inappropriate for psychologists to engage in, occurred following psychotherapists appearing to travel down the slippery slope, it was believed that all boundary violations, and even all boundary crossings, placed the psychotherapist at risk of sliding down the slippery slope, thus risking harm to the client. Accordingly, it was strongly recommended that psychotherapists take a very conservative view of boundaries and be very cautious about ever crossing them, due to the perceived risk of harm that would likely occur when the psychotherapist lost control of this process (Gutheil & Gabbard, 1993). Thus, even apparently well-intentioned and seemingly benign boundary crossings were viewed as holding the potential to lead down the slippery slope and thus should be avoided. A hypothesized representative example of the slippery slope phenomenon might involve the following behaviors over time: shaking a client’s hand when greeting each other at the beginning of treatment sessions, engaging in the judicious use of self-disclosure as a treatment technique, extending the client’s session length due to clinical need, engaging in increased use of self-disclosure to include personal information, having contact with the client in between sessions through repeated e-mails or telephone calls, meeting with the client outside of scheduled treatment sessions, increased personal sharing and nonerotic touch, and then entering into a sexually intimate relationship.
Current Thinking While evidence of the slippery slope exists and there are documented cases of psychologists and other mental health professionals engaging in these behaviors, one must question if boundaries can be crossed and have this not lead to inappropriate or harmful behaviors. It is true that in some circumstances, some psychotherapists have moved down the slippery slope, resulting in inappropriate sexual relationships with clients (Pope, Tabachnick, & Keith-Spiegel, 1988), yet no evidence exists that suggests that crossing one boundary will definitely lead to violating others (Lazarus & Zur, 2002). The historical assumption that because inappropriate sexual intimacies are preceded by increasingly intrusive and inappropriate boundary incursions, that all boundary crossings will therefore lead to sexually intimate relations between psychotherapist and client, is a fallacy of logic and not supported by the existing literature. Authors such as Gottlieb and Younggren (2009) have questioned if every boundary crossing places the psychotherapist on the slippery slope and for that matter, if the slippery slope even exists. These authors cite a broad literature that acknowledges the fact that in some circumstances and situations, and at times for some psychotherapists, the slippery slope may exist, but in many situations and with many psychotherapists, it does not. There are numerous occasions where psychotherapists engage in boundary crossings that are clinically appropriate and that do not lead to subsequent boundary violations (e.g., Lazarus & Zur, 2002; Zur, 2007). Examples include the clinically relevant and therapeutic use of self-disclosure, extending the time of a treatment session, for a client who is in crisis, accepting a small gift from a client at the final treatment session or hugging a grieving client. Gottlieb and Younggren (2009) articulate the need for flexibility in approaching boundaries since each client–psychotherapist dyad is different, and the circumstances surrounding each client’s needs vary and must be considered when making decisions about boundaries.
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Not only is a rigid and avoidant approach to boundary crossings uncalled for, but in many situations with many clients, to avoid certain boundary crossings (and to avoid certain multiple relationships) would in fact be harmful to the client and to the psychotherapy relationship. As Lazarus (1994) points out, this rigid approach often results in “artificial boundaries that serve as destructive prohibitions and thereby undermine clinical effectiveness” (p. 255). Numerous examples are cited in the relevant literature such as a refusal to touch a grieving client, the refusal to accept a small holiday gift from a child client, and refusing ever to self-disclose to a client out of a misguided fear that doing so might lead to an inappropriate multiple relationship. Such actions are not only misguided, they frequently are not even possible to enforce. For example, psychotherapists engage in various forms of self-disclosure all the time. The way psychotherapists dress, the jewelry one wears (to include an engagement ring or wedding band), the accent with which one speaks, and the physical manifestations of pregnancy are all types of self-disclosure (Zur, 2007). To suggest that a psychotherapist might avoid all self-disclosure is unrealistic. Of course, a distinction can be made between these inadvertent forms of selfdisclosure and the intentional disclosure of personal feelings toward a client. Yet, with attention to the guiding principles described earlier, self-disclosure (and all boundary crossings, for that matter) may be appropriately engaged in, and without fear of stepping onto a slippery slope that will inevitably lead to sexually intimate behavior with a client.
Sexual Attraction and Behaviors It is widely accepted that psychotherapists experience feelings of sexual attraction toward clients and engage in sexual fantasies about clients (Pope, Tabachnick, & Keith-Spiegel, 1987; Pope, Sonne, & Greene, 2006). This is a naturally occurring phenomenon that exists whether or not it is acknowledged and appropriately addressed. In fact, Pope, Tabachnick, and Keith-Spiegel (1986) found that 87% of psychotherapists they surveyed acknowledged having been sexually attracted to one or more clients. The issue of sexual feelings or attraction toward clients is one that has not received significant attention in the relevant literature and one that frequently is not addressed openly in the training of psychotherapists, be it in the academic setting or in clinical supervision. Pope and Tabachnick (1993) report that the majority of psychologists they surveyed report that their training in graduate school about these issues was poor or nonexistent. As a result, psychotherapists are often ill-prepared to respond to these feelings in a healthy, adaptive, and clinically appropriate manner. As Pope, Tabachnick, and Keith-Spiegel (1986) note, psychotherapists often respond to the experience of sexual attraction toward clients with feelings of guilt, shame, and confusion. As a result, many psychotherapists will minimize or avoid addressing their sexual attraction toward clients, possibly missing the opportunity to consider important clinical issues that are relevant to the client’s treatment. Additionally, this avoidance may create discomfort and anxiety on the part of the psychotherapist that the client may perceive, resulting in confusion or discomfort for the client that may adversely impact the psychotherapy relationship and process. Pope et al. (2006) address how the experience of sexual feelings toward or fantasies about clients is for many psychotherapists inconsistent with the view they hold of themselves as caring professionals. An acknowledgement of these feelings may create dissonance for the psychotherapist who must reconcile these very personal feelings with their professional role, image, and obligations. What often appears to be easiest is to push these feelings aside, avoiding addressing their existence and presence. These authors acknowledge that for many years, sexual feelings toward clients and sexual fantasies about clients have been taboo topics within the mental health professions. Students and supervisees may perceive their instructors’ and supervisors’ discomfort with openly addressing these topics. In addition to leaving trainees ill-prepared for appropriately responding to these experiences, it may contribute to the development of the shame, guilt, and anxiety that so many psychotherapists experience in response to these feelings (Ladany, Klinger, & Kulp, 2011). Pope et al. (2006) raise the possibility that psychotherapists may avoid addressing these naturally occurring feelings of attraction toward clients out of a fear of acting on them. Psychotherapists may view the acknowledgement of these feelings as a first step down the slippery
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slope that will lead them to engaging in sexual activity with clients. Rather than openly addressing and working to understand the clinical significance of these feelings in clinical supervision, psychotherapists may avoid addressing them out of shame or embarrassment, or in the na¨ıve hope that denying their existence will somehow cause these uncomfortable feelings to cease to exist. There is a clear difference between feeling attracted to a client and engaging in sexual behaviors with a client. Yet, these two topics seem inextricably linked and a potential source of confusion for many psychotherapists. While all psychotherapists who engage in sexual behaviors with clients first experience sexual attraction to these clients, only a very small percent of psychotherapists who experience sexual attraction to clients ever act on this attraction and engage in sexually intimate relations with clients. While more research is needed to better understand the link between these two phenomena, it is evident that avoidance, denial, and minimization are not likely to assist psychotherapists to effectively make sense of and appropriately manage these feelings.
Underlying Causes A number of reasons may be postulated for why psychologists may engage in boundary violations and inappropriate multiple relationships, to include sexually intimate relations with clients. These include naivety, problems with professional competence, and character issues.
Naivety The na¨ıve psychologist is one who may be uneducated, uninformed, or unaware of issues relevant to boundaries, multiple relationships, sexual feelings and fantasies, the slippery slope, standards of practice, and ethical decision making. While training in ethics is a requirement of APAaccreditation for doctoral programs in psychology, it is not known how much focus is placed on these issues. As has been reviewed, many psychologists report inadequate attention to these issues during their training. Failure to openly discuss feelings of physical or sexual attraction in clinical supervision adds to the risk of a na¨ıve approach to addressing these issues when one leaves graduate school and enters clinical practice. Psychotherapists may also be na¨ıve about their ability to control, deny, or independently manage their feelings of attraction toward clients. Instead of openly discussing and processing these feelings in clinical supervision or through consultation with trusted colleagues, they may naively believe that they can “handle it” or that if they ignore these thoughts and feelings they will just go away. Naivety about ethics standards and practices is never a justifiable excuse for engaging in inappropriate or unethical conduct. The APA Ethics Code (APA, 2010) makes this clear in stating that members must be aware of and follow the standards in the APA Ethics Code and that “lack of awareness or misunderstanding of an Ethical Standard is not itself a defense to a charge of unethical conduct” (p. 1). Yet a lack of awareness or understanding of the issues relevant to boundaries, multiple relationships, physical attraction to clients, ethics standards, ethical decision making, and sexual intimacies with clients can be seen as one possible explanation of how psychologists may engage in these behaviors.
Problems With Professional Competence It is widely accepted that the practice of psychotherapy is a demanding endeavor that places the clinician at risk for distress and burnout if ongoing challenges and stresses are not adequately managed (O’Connor, 2001). Psychologists must manage challenges and demands in both their professional and personal lives. Professional challenges may include difficult clients, clients who relapse or do not improve, clients who attempt or commit suicide, administrative and financial challenges, and others such as having clients with poor boundaries who act out sexually and test boundaries with the psychotherapist. Challenges in one’s personal life may include relationship difficulties, family illness, and financial stressors, as well as suffering from mental health difficulties such as depression, anxiety disorders, and substance abuse. Both sets of
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challenges interact and influence each other, often creating a level of distress that can adversely impact the psychologist’s decision-making abilities, judgment, and clinical competence (Barnett, 2008). While distress, burnout, and the impairment in professional judgment and functioning they may cause are not justifications for engaging in sexually inappropriate behaviors with clients, they often are contributing factors. As Smith and Fitzpatrick (1995) describe: To date, the most common profile to emerge is that of a middle-aged male therapist who is professionally isolated and is currently undergoing some personal distress or midlife crisis, often including marital problems. This so-called “lovesick” therapist typically begins his descent down the slippery slope by sharing his own problems and exposing his own vulnerability to a younger female client. (p. 504) Failure to proactively and effectively manage the stressors in one’s professional and personal lives, failure to engage in the ongoing practice of self-care to promote wellness, and a tendency to isolate oneself are all factors that may conspire to create conditions in which a psychotherapist may begin violating boundaries in an effort to get personal needs met through clients, greatly increasing the likelihood of inappropriate sexually intimate relations with clients occurring.
Character Issues It can be assumed that most individuals who enter the profession of psychology do so with good intentions. Yet there are those who, despite knowing their professional obligations and with forethought, choose to prey on the vulnerabilities of their clients and take advantage of them through sexually intimate behaviors. These professionals are described by Brayfield-Cave (1991) as “predators of the profession” (p. 7). While data on the percent of psychologists who fall into this category are not readily available, licensing board complaints, ethics committee complaints, and malpractice suit data indicate that such professionals do exist (Gottlieb & Younggren, 2009). This highlights the need for educators, trainers, and clinical supervisors to take very seriously their roles as gatekeepers of the profession, carefully monitoring students and trainees and not allowing those who appear unfit or unsuitable for the role of psychotherapist to enter into the profession (Johnson, Elman, Forrest, Rodolfa, & Schaffer, 2008). Also of great importance is the role of ethics committees and licensing boards. They must create and disseminate clear standards for sexually intimate behaviors and actively and uniformly enforce them.
Prevention and Positive Action There are numerous steps that can be taken to help minimize the risk of psychologists engaging in inappropriate sexual relations with clients. Knowledge of the APA Ethics Code and prevailing professional standards is an important first step, but as has been highlighted, psychotherapists must be cognizant of their own emotional needs and functioning, mindful of the power differential in the professional relationship, careful not to abuse their clients’ trust and dependence, and ever mindful of boundaries and multiple relationships. In doing so, it is very important to be self-aware and honest about when personal needs, vulnerabilities, and conflicts may be placing the psychologist at increased risk of violating boundaries. As Johnson, Barnett, Elman, Forrest, and Kaslow (2012) emphasize, psychologists, like other health professionals, are notoriously poor at self-assessing their competence and level of functioning, frequently overestimating their capabilities and underestimating their levels of distress and impairment. It is therefore of great importance that psychologists not isolate themselves professionally. Rather, consultation with colleagues should be seen as an essential element of each psychologist’s decision-making process when faced with questions about the appropriateness of planned actions and behaviors. It is further recommended that psychologists participate in ongoing peer consultation and support groups so that they will have a forum for openly discussing boundary and multiple relationship issues in a supportive environment where honest feedback may be received.
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When considering crossing boundaries with clients, it essential that each client’s individual differences be considered, to include presenting problems, treatment needs and challenges, personality pathology and history of boundary difficulties, and diversity issues relevant to understanding the potential impact of planned boundary incursions on the client. This recommendation is consistent with Lazarus’ (1994) admonition against rigid rules about boundaries and highlights the need for a deliberative approach in considering each potential boundary crossing. Psychologists who are educators, trainers, and clinical supervisors should openly discuss feelings of sexual attraction to clients with their students, trainees, and supervisees. The existence of these feelings needs to be normalized to minimize shame and the resulting avoidance of proactively addressing these feelings. Additionally, psychologists-in-training should be educated about boundaries, multiple relationships, and their responsibility to act based on a primary focus on each client’s best interests. Both psychologists-in-training and practicing psychologists should consider participation in personal psychotherapy when sexual feelings and fantasies about clients are preoccupying them and interfere with effective clinical practice. Additionally, when concerns about maintaining objectivity and judgment exist and when a risk of exploitation arises, personal psychotherapy for the clinician should be considered to address and work through underlying issues that may be creating the risky situation. When faced with ethical dilemmas, situations with no clearly evident right or wrong answer, it is important to utilize an ethical decision-making process to reason through the situation so that the best possible decision can be made. Younggren and Gottlieb (2004, pp. 256–257) suggest asking the following questions to aid in making decisions about potentially inappropriate actions with clients: (a) Is entering into the secondary relationship necessary, or should I avoid it? (b) Can the multiple relationship potentially cause harm to the client? (c) If harm seems unlikely or avoidable, would the additional relationship prove beneficial? (d) Is there a risk that the secondary relationship could disrupt the therapeutic relationship? (e) Can I evaluate this matter objectively? Additionally, when considering boundary incursions psychologists should consider their motivations and whose needs are being met, the relevance of the planned action to the client’s treatment needs and plan, if they are comfortable documenting the intended action and discussing it with colleagues, and if they have discussed the planned action with the client and considered his or her comfort and preferences. When considering posttermination intimate relationships with clients, psychotherapists are additionally advised to consider the requirements of Standard 10.08, Sexual Intimacies with Former Therapy Clients/Patients, of the APA Ethics Code (APA, 2010). Because these relations are typically so harmful and inappropriate, they are forbidden for 2 years from the date of last professional contact with the client. Then after this time period transpires, psychologists must consider the following seven factors when deciding on the appropriateness of entering the posttreatment sexual relationship to demonstrate that no exploitation is occurring: (1) the amount of time that has passed since therapy terminated; (2) the nature, duration, and intensity of the therapy; (3) the circumstances of termination; (4) the client’s/patient’s personal history; (5) the client’s/patient’s current mental status; (6) the likelihood of adverse impact on the client/patient; and (7) any statements or actions made by the therapist during the course of therapy suggesting or inviting the possibility of a posttermination sexual or romantic relationship with the client/patient. (p. 13)
Case Illustration Dr. Green is a 50-year old, male psychologist with over 25 years of solo private practice experience as a psychotherapist. His practice focuses on the treatment of depression, anxiety, and stressrelated difficulties in adults. Dr. Green has been married for over 20 years, but in recent months he has grown dissatisfied with his relationship, feeling alienated from his wife, viewing her as unsympathetic to the stressful nature of his work, and often preoccupied with and focused
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on her own issues. Dr. Green feels under pressure financially and is resentful of the money his wife spends on clothing, leisure time activities, and decorating their home. Dr. Green has found himself withdrawing from his wife emotionally, working longer hours, and, most recently, stopping off at a local restaurant for one or two alcoholic drinks before coming home in the evening to eat dinner alone, read, and then fall asleep. Dr. Green has also recently been spending time thinking about an attractive female client, Sharon Jones, both when out of the office and while meeting with other clients. He finds that he greatly enjoys their sessions and finds her to be a very interesting individual. Their insession discussions have recently ventured beyond her treatment issues of feelings of loneliness and general relationship dissatisfaction, with Dr. Green finding himself having a great deal in common with her. At times, Dr. Green shares about their common interests during their sessions. Between sessions he finds himself fantasizing about what a relationship with Ms. Jones would be like, but dismisses these thoughts, saying to himself that this would never happen. This week, one evening after work when he enters the restaurant, Dr. Green notices Ms. Jones sitting at the bar having a drink. She notices him walking in, makes eye contact, and waves hello. Not wanting to be rude, Dr. Green walks over and greets her. As they chat, he sits down next to her and then orders his drink. As they continue speaking about how their day went, common interests, and the like, Dr. Green becomes aware of how enjoyable this is. They talk, laugh, and drink together, at times casually touching each other on the forearm when agreeing with something the other has said.
Discussion Dr. Green fits the general description of the “lovesick therapist” described earlier (Smith & Fitzpatrick, 1995). He is an older male who is interacting with an attractive, younger female client. He is experiencing feelings of alienation and lack of emotional support in his marriage and appears to be getting some of his emotional needs met through his interactions with his client. This occurs first during treatment sessions when he expands discussions beyond the client’s treatment needs and ventures into sharing about their common interests. Dr. Green also finds himself thinking of this client during work and away from the office, but seems unaware of this as a sign that closer examination of the situation is needed. Dr. Green appears to be isolated personally and professionally. Rather than work with his wife to address the issues in their relationship and his feelings of lack of support, appreciation, and understanding, he has been withdrawing from her further by spending more time at work and using alcohol as a means of responding to and coping with these difficulties. With regard to his preoccupation with his client, there is no acknowledgement of any concerns about this, his fantasies about her (to include when in session with other clients), how he is coping with the stresses in his life, or that his objectivity or judgment may in any way be becoming increasingly impaired. Rather, Dr. Green appears to be getting some of his emotional needs met through his relationship with Ms. Jones, a relationship that has been increasingly shifting from a professional one to a more personal one.
Analysis and Recommendations Based on the information provided, it appears that Dr. Green is well on his way down the slippery slope, perhaps moving rapidly toward entering an intimate relationship with Ms. Jones: Dr. Green is isolated personally and professionally; he has not taken actions to address the stresses and frustrations in his personal life; he is using the relationship with a client to meet his own emotional needs; and he has failed to consider how the changes in the relationship with Ms. Jones may be adversely impacting his objectivity and judgment, and how they may be harmful to Ms. Jones over time. Upon noticing himself feeling attracted to Ms. Jones and becoming preoccupied with thoughts about her, Dr. Green should have sought out consultation with an experienced colleague and perhaps even have sought out ongoing clinical supervision from a colleague with expertise in boundary issues and multiple relationships. Through this consultation and supervision, Dr.
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Green could openly discuss all the details relevant to life circumstances, feelings, fantasies, and desires. With this colleague, decisions could be made about the appropriateness of continuing Ms. Jones’ psychotherapy, if referring her to another professional would be in her best interest, if personal psychotherapy for Dr. Green would be appropriate (to include addressing his use of alcohol), and if marriage counseling would be appropriate for Dr. Green and his wife. Further, it is hoped that Dr. Green would receive education about boundaries and multiple relationships in psychotherapy, how feelings of attraction to clients should be addressed, and how ongoing challenges and stresses in his personal life can impact his professional functioning and should be addressed.
Conclusions Boundaries and multiple relationships are complex issues that if not addressed and managed appropriately, can lead to harm to clients. While sexually intimate relations with clients are widely accepted as inappropriate and harmful to clients, psychologists who do not take appropriate precautions and do not engage in a thoughtful decision-making process may find themselves acting in ways that are inconsistent with the ethics standards of the profession and place clients at significant risk of exploitation and harm. While no rigid rules exist for managing boundaries and multiple relationships, relevant factors to consider have been reviewed and recommendations for ethical practice have been made. With thoughtful attention to clients’ needs and best interests, prevailing professional standards, ethical decision making, personal needs and stressors, and education about these issues, it is hoped that psychologists will successfully navigate these challenges in a manner consistent with the highest ethics standards of the profession.
Selected References and Reading Recommendations American Psychological Association. (2010). Ethical principles of psychologists and code of conduct. Retrieved from http://www.apa.org.ethics Barnett, J. E. (2008). Impaired professionals: Distress, professional impairment, self-care, and psychological wellness. In M. Herson & A. M. Gross (Eds.), Handbook of clinical psychology (Vol. 1, pp. 857–884). New York: John Wiley & sons. Barnett, J. E., Lazarus, A. A., Vasquez, M. J. T., Morehead-Slaughter, O., & Johnson, W. B. (2007). Boundary issues and multiple relationships: Fantasy and reality. Professional Psychology: Research and Practice, 38(4), 401–410. Brayfield-Cave, S. (1991). Sexual predators in the profession. Register Report, 17, 7–8. Gabbard, G. O. (1989). Sexual exploitation in professional relationships. Washington, DC: American Psychiatric Association. Gottlieb, M. C., & Younggren, J. N. (2009). Is there a slippery slope? Considerations regarding multiple relationships and risk management. Professional Psychology: Research and Practice, 40(6), 564–571. Gutheil, T. G., & Gabbard, G. O. (1993). The concept of boundaries in clinical practice: Theoretical and risk management dimensions. American Journal of Psychiatry, 150, 188–196. Johnson, W. B., Barnett, J. E., Elman, N., Forrest, L., & Kaslow, N. J. (2012). The competent community: Toward a radical reformulation of professional ethics. American Psychologist, 67(7), 557–569. Johnson, W. B., Elman, N. S., Forrest, L., Robiner, W. N., Rodolfa, E., & Schaffer, J. B. (2008). Addressing professional competence problems in trainees: Some ethical considerations. Professional Psychology: Research and Practice, 39(6), 589–599. Knapp, S. J., & VandeCreek, L. D. (2012). Practical ethics for psychologists: A positive approach (2nd ed.). Washington, DC: APA Books. Ladany, N., Klinger, R., & Kulp, L. (2011). Therapist shame: Implications for therapy and supervision. In R. L. Dearing & J. P. Tangney (Eds.), Shame in the therapy hour (pp. 307–322). Washington, DC: American Psychological Association. Lazarus, A. A. (1994). How certain boundaries and ethics diminish therapeutic effectiveness. Ethics & Behavior, 4, 255–261. Lazarus, A. A., & Zur, O. (Eds.) (2002). Dual relationships and psychotherapy. New York: Springer.
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O’Connor, M. F. (2001). On the etiology and effective management of professional distress and impairment among psychologists. Professional Psychology: Research and Practice, 32(4), 345–350. Pope, K. S., Keith-Spiegel, P., & Tabachnick, B. G. (2006). Sexual attraction to clients: The human therapist and the (sometimes) inhuman training system. Training and Education in Professional Psychology, S(2), 96–111. Pope, K. S., Sonne, J. L., & Greene, B. (2006). What therapists don’t talk about and why: Understanding taboos that hurt us and our clients. Washington, DC: American Psychological Association. Pope, K. S., & Tabachnick, B. G. (1993). Therapists’ anger, hate, fear, and sexual feelings: National survey of therapist responses, client characteristics, critical events, formal complaints, and training. Professional Psychology: Research & Practice, 24, 142–152. Pope, K. S., Tabachnick, B. G., & Keith-Spiegel, P. (1986). Sexual attraction to clients: The human therapist and the (sometimes) inhuman training system. American Psychologist, 41, 147–158. Pope, K. S., Tabachnick, B. G., & Keith-Spiegel, P. (1987). Ethics of practice: The beliefs and behaviors of psychologists as therapists. American Psychologist, 42, 993–1006. Pope, K. S., Tabachnick, B. G., & Keith-Spiegel, P. (1988). Good and poor practices in psychotherapy: National survey of beliefs of psychologists. Professional Psychology: Research and Practice, 19(5), 547– 552. Smith, D., & Fitzpatrick, M. (1995). Patient–therapist boundary issues: An integrative review of theory and research. Professional Psychology: Research and Practice, 26(5), 499–506. Sonne, J. (2013). The “vicissitudes of love” between therapist and patient: A review of the research on romantic and sexual feelings, thoughts, and behaviors in psychotherapy. Journal of Clinical Psychology, 70(2), 182–195. Younggren, J. N., & Gottlieb, M. C. (2004). Managing risk when contemplating multiple relationships. Professional Psychology: Research and Practice, 35(3), 255–260. Zur, O. (2007). Boundaries in psychotherapy. Washington, DC: American Psychological Association.
Each of the mental health professions makes very clear in their codes of ethics the importance of establishing and maintaining clear boundaries between clinicians and those they serve (e.g., clients, supervisees, and students) to prevent actions and behaviors that may lead to exploitation of, or harm to, these individuals. The Ethical Principles of Psychologists and Code of Conduct (American Psychological Association [APA] Ethics Code; APA, 2010) includes standards that forbid sexual intimacies with current psychotherapy clients and patients (Standard 10.05), sexual intimacies with relatives or significant others of current psychotherapy clients and patients (Standard 10.06), and psychotherapy with former sexual partners (Standard 10.07). Additionally, Standard 10.08, Sexual Intimacies With Former Therapy Clients/Patients, forbids psychologists from engaging in sexually intimate relationships with former clients for a minimum of 2 years from the date of last professional contact and even then, only “in the most unusual circumstances” (p. 13). This standard then goes on to specify seven factors that psychologists must consider when deciding if such an activity will be appropriate and meet this “unusual circumstance” criterion. Additional standards in the APA Ethics Code (APA, 2010) apply this general prohibition against sexually intimate relationships to all those psychologists interact with in their professional roles. For example, Standard 7.07, Sexual Relationships With Students and Supervisees, forbids psychologists from engaging in sexually intimate relationships with any student or supervisee “over whom psychologists have or are likely to have evaluative authority” (p. 10). It is made clear in the APA Ethics Code (APA, 2010) that sexually intimate relationships with clients and others that psychologists interact with in their professional roles should be avoided. Yet not all multiple relationships with clients and others are viewed as inappropriate or unethical. In fact, Standard 3.05, Multiple Relationships, articulates that: A psychologist refrains from entering into a multiple relationship if the multiple relationship could reasonably be expected to impair the psychologist’s objectivity,
Please address correspondence to: Jeffrey E. Barnett, Department of Psychology, Loyola University Maryland, 4501 N. Charles Street, Baltimore, MD 21210. E-mail: [email protected] C 2013 Wiley Periodicals, Inc. JOURNAL OF CLINICAL PSYCHOLOGY: IN SESSION, Vol. 70(2), 170–181 (2014) Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp). DOI: 10.1002/jclp.22068
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competence or effectiveness in performing his or her functions as a psychologist, or otherwise risks exploitation or harm to the person with whom the professional relationship exists. (p. 6) This standard is consistent with the overarching requirement psychologists have to avoid harming others. Standard 3.04, Avoiding Harm, states: “Psychologists take reasonable steps to avoid harming their clients/patients, students, supervisees, research participants, organizational clients, and others with whom they work, and to minimize harm where it is foreseeable and unavoidable” (p. 6). Additionally, Standard 3.06, Conflict of Interest, requires psychologists to avoid all relationships that “could reasonably be expected to (1) impair their objectivity, competence, or effectiveness in performing their functions as psychologists or (2) expose the (client) to harm or exploitation” (p. 6). Taken together, these ethics code standards articulate the profession of psychology’s current thinking on sexually intimate behaviors and relationships with those psychologists interact with professionally. Yet despite these prohibitions, such behaviors occur, estimated to be engaged in by up to 9.4% of male psychotherapists and by up to 2.5% of female psychotherapists (Pope, Keith-Spiegel, & Tabachnick, 2006), resulting in significant harm to individuals who had entrusted psychologists with their welfare, along with harm to the reputation of the profession of psychology, and possibly even to the public in general who may avoid seeking needed mental health treatment services as a result of a lack of trust of psychologists in general. Thus, prohibitions in the profession’s ethics code are not sufficient for preventing these harmful behaviors from occurring. With greater understanding of the underlying causes of these behaviors, it is hoped that steps can be taken to minimize the likelihood of their occurrence in the future, for the benefit of all involved.
The Psychotherapy Relationship and Professional Obligations Psychologists provide professional services to clients in the context of relationships that are built upon trust. Clients regularly share their most closely held secrets, fears, insecurities, and vulnerabilities with their psychologist, things they may never have shared with another person, in the hope of receiving assistance that will result in the resolution of underlying conflicts, issues, and distress (Barnett, Lazarus, Vasquez, Moorehead-Slaughter, & Johnson, 2007). This creates dependence on the psychologist and vulnerability for the client. Clients rely on and trust their psychologist to utilize the information shared solely for the purpose of assisting the client to achieve his or her treatment goals, and not to satisfy the psychologist’s personal needs or interests. This focus on trust and psychologists’ obligations to their clients is seen in the aspirational General Principle B: Fidelity and Responsibility, of the APA Ethics Code (APA, 2010), which states: Psychologists establish relationships of trust with those with whom they work. They are aware of their professional and scientific responsibilities to society and to the specific communities in which they work. Psychologists uphold professional standards of conduct, clarify their professional roles and obligations, accept appropriate responsibility for their behavior and seek to manage conflicts of interest that could lead to exploitation or harm. (p. 3) Thus, it is essential that psychologists are mindful of their obligations to clients, to include avoiding all actions and behaviors that hold the potential to be harmful to, or exploitative of, clients. As Principle B, above, explains, psychologists also have responsibilities to society at large; in addition to not taking advantage of clients’ dependence and trust, they must not engage in actions that will violate the public’s trust of the profession in general.
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Boundaries and Multiple Relationships Boundaries By need and design, the psychotherapy relationship is different from all other relationships that both client and psychotherapist enter into. As such, this relationship is guided by a set of boundaries that help clarify and define appropriate behaviors and expectations. Boundaries are defined by Knapp and VandeCreek (2012) as the “rules of the professional relationship that set it apart from other relationships” and that “clarify which behaviors are appropriate and inappropriate in psychotherapy” (p. 87). The presence of boundaries in the psychotherapy relationship helps to promote a safe and trusting environment in which clients may receive needed treatment services without risking exploitation or harm. Boundaries “provide a foundation for this relationship by fostering a sense of safety and the belief that the clinician will always act in the client’s best interest” (Smith & Fitzpatrick, 1995, p. 500). A number of different boundaries exist that typically are relevant to the psychotherapy relationship. These include location, time, interpersonal space, self-disclosure, touch, and gifts. Boundaries may be avoided, crossed, or violated. As will be seen, there is a certain amount of flexibility appropriate for how psychologists address and manage boundaries, and a decisionmaking process is often needed to guide psychologists in how to best do so in some situations. But boundaries cannot be overlooked or ignored and must be thoughtfully considered in all psychotherapy relationships. To avoid a boundary means to not engage in the behavior in question. As an example, one can have a rule that prohibits ever engaging in any form of touch with clients, such as on an inpatient unit where any use of touch might possibly be misconstrued by a patient or when providing psychotherapy to a client with a history of sexual trauma for whom a casual hand on the shoulder might be traumatizing. A boundary crossing involves transgressing the boundary, but is not considered to be inappropriate, unwelcomed, or harmful, such as shaking a client’s extended hand upon meeting him or her for the first time or hugging a client who is grieving if welcomed by that client. A boundary violation, by definition, involves transgressing a boundary in a manner that is considered to hold a significant potential for exploitation or harm, that violates accepted professional standards, or that is unwelcomed (Smith & Fitzpatrick, 1995). Examples of boundary violations may include inappropriate or sexual touch or other intimate or unwelcomed physical contact. Each of the above-mentioned boundaries may be avoided, crossed, or violated. Certainly, what it means to avoid a boundary is likely to be widely agreed upon (e.g., never engaging in any touch with clients and never accepting a gift from a client). While there are some widely accepted standards with regard to whether a particular behavior is viewed as a boundary crossing or boundary violation (e.g. what constitutes an inappropriate self-disclosure and sexually intimate physical contact with a client), in many situations the use of a deliberative decision-making process is needed to help determine the appropriateness of one’s behaviors. Factors to consider that help determine if a particular behavior would constitute a boundary crossing or a boundary violation are as follows.
The client’s presenting problems, mental health history, and the nature of the treatment being provided. What constitutes a boundary crossing versus a boundary violation may be impacted by the nature of the client’s presenting problems and the length and intensity of the treatment being provided. These factors may impact the client’s level of dependence on the psychologist as well as the client’s vulnerability to the psychologist’s influence. For example, a client who presents with dependence issues, a need to please authority figures, and emotional vulnerability may be at greater risk of exploitation or harm and the psychologist may therefore need to exercise greater caution when considering boundaries.
The psychologist’s intent. It is vital that decisions made about boundaries be based on a thoughtful appraisal of the client’s best interests and treatment needs. Boundary decisions should never be made based on the gratification of the psychologist’s personal needs. Such
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actions would be inimical to psychologists’ responsibilities to only act in the client’s best interests.
If the client welcomes the action or not. If a client does not welcome an action or behavior, then, by definition, it is a boundary violation because it is violating the client’s comfort or desires and should not be engaged in. But even if a client welcomes an action on the psychologist’s part, this does not mean that the behavior is a boundary crossing. As is addressed above, clients may have emotional vulnerabilities, dependence on the psychologist’s view of them, and an inability to exercise autonomous decision making. Psychologists must engage in decision making that places paramount emphasis on the client’s needs and best interests. The psychologist’s theoretical orientation. Psychologist theoretical orientation factors may also impact views of boundaries. For example, the use of self-disclosure and touch may be more consistent with the perspectives held by humanistic psychotherapists as opposed to psychoanalytic or psychodynamic psychotherapists. Cognitive behavioral psychotherapists may view providing treatment in a client’s home differently than psychodynamic psychotherapists (e.g., to treat agoraphobia). Diversity issues and prevailing community standards. Psychologists’ actions and behaviors may be viewed quite differently by individuals from culturally diverse groups and backgrounds. Attention to prevailing community standards is important since normative behaviors may vary by group. Some cultural groups may give gifts as a gesture of appreciation for assistance provided and to refuse the gift may be interpreted as an insult. Some groups may kiss others on each cheek upon greeting them each time they meet. Failure to attend to individual and group differences may result in violating boundaries and potentially harming the psychotherapy relationship unintentionally. Multiple Relationships Multiple relationships are those situations in which a psychologist is engaged in one or more additional relationships with a client in addition to the treatment relationship. Multiple relationships may be sexual or nonsexual. Nonsexual multiple relationships may include social, familial, business or financial relationships, and possibly others. Multiple relationships are distinguished from incidental contacts. Incidental contacts are situations in which the psychologist and client have an interaction in another setting that is unplanned and very brief. Examples may include noticing that the psychologist and client are attending the same concert or community event, being members of the same organization, or briefly crossing paths in the community. As the APA Ethics Code (APA, 2010) clearly states in Standard 3.05, Multiple Relationships, not all multiple relationships are to be avoided or are to be considered inappropriate. In fact, this standard clarifies that only those multiple relationships that are likely to lead to exploitation or harm of the client and/or that are likely to adversely impact the psychologist’s objectivity and judgment should be avoided. Multiple relationships that do not meet these criteria do not need to be avoided and, in some circumstances, are appropriate, enriching, and often even essential for meeting the client’s best interests (Lazarus & Zur, 2002). Multiple relationships may also involve sexually intimate behaviors and may occur concurrently such as entering into a romantic or sexual relationship with a current client or an individual closely related to or associated with the client, or sequentially such as accepting into treatment a former lover or entering into an intimate relationship with a former client. As has been reviewed, the APA Ethics Code (APA, 2010) addresses each of these circumstances in enforceable standards that prohibit the first two under all circumstances and allows only for the later type of multiple relationships in certain rare circumstances. As will be reviewed below and described in detail by Sonne (2013), each of these types of multiple relationships brings with them significant potential for exploitation, abuse of trust and dependence, and inevitable harm to the client or former client.
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A Historical Context The early literature on sexually intimate multiple relationships viewed them from a psychodynamic perspective that focused on mismanagement of the transference relationship by the psychotherapist (Gutheil & Gabbard, 1993). Additionally, it was noted that sexually intimate multiple relationships between psychotherapists and their clients typically occurred after a series of increasingly intrusive and inappropriate behaviors over time, a process termed “the slippery slope” (Gabbard, 1989). From a boundaries perspective, it was hypothesized that psychotherapists move from boundary crossings to boundary violations, each increasingly placing the client’s welfare at risk. Because of the fact that sexually intimate multiple relationships with clients, which are always harmful and inappropriate for psychologists to engage in, occurred following psychotherapists appearing to travel down the slippery slope, it was believed that all boundary violations, and even all boundary crossings, placed the psychotherapist at risk of sliding down the slippery slope, thus risking harm to the client. Accordingly, it was strongly recommended that psychotherapists take a very conservative view of boundaries and be very cautious about ever crossing them, due to the perceived risk of harm that would likely occur when the psychotherapist lost control of this process (Gutheil & Gabbard, 1993). Thus, even apparently well-intentioned and seemingly benign boundary crossings were viewed as holding the potential to lead down the slippery slope and thus should be avoided. A hypothesized representative example of the slippery slope phenomenon might involve the following behaviors over time: shaking a client’s hand when greeting each other at the beginning of treatment sessions, engaging in the judicious use of self-disclosure as a treatment technique, extending the client’s session length due to clinical need, engaging in increased use of self-disclosure to include personal information, having contact with the client in between sessions through repeated e-mails or telephone calls, meeting with the client outside of scheduled treatment sessions, increased personal sharing and nonerotic touch, and then entering into a sexually intimate relationship.
Current Thinking While evidence of the slippery slope exists and there are documented cases of psychologists and other mental health professionals engaging in these behaviors, one must question if boundaries can be crossed and have this not lead to inappropriate or harmful behaviors. It is true that in some circumstances, some psychotherapists have moved down the slippery slope, resulting in inappropriate sexual relationships with clients (Pope, Tabachnick, & Keith-Spiegel, 1988), yet no evidence exists that suggests that crossing one boundary will definitely lead to violating others (Lazarus & Zur, 2002). The historical assumption that because inappropriate sexual intimacies are preceded by increasingly intrusive and inappropriate boundary incursions, that all boundary crossings will therefore lead to sexually intimate relations between psychotherapist and client, is a fallacy of logic and not supported by the existing literature. Authors such as Gottlieb and Younggren (2009) have questioned if every boundary crossing places the psychotherapist on the slippery slope and for that matter, if the slippery slope even exists. These authors cite a broad literature that acknowledges the fact that in some circumstances and situations, and at times for some psychotherapists, the slippery slope may exist, but in many situations and with many psychotherapists, it does not. There are numerous occasions where psychotherapists engage in boundary crossings that are clinically appropriate and that do not lead to subsequent boundary violations (e.g., Lazarus & Zur, 2002; Zur, 2007). Examples include the clinically relevant and therapeutic use of self-disclosure, extending the time of a treatment session, for a client who is in crisis, accepting a small gift from a client at the final treatment session or hugging a grieving client. Gottlieb and Younggren (2009) articulate the need for flexibility in approaching boundaries since each client–psychotherapist dyad is different, and the circumstances surrounding each client’s needs vary and must be considered when making decisions about boundaries.
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Not only is a rigid and avoidant approach to boundary crossings uncalled for, but in many situations with many clients, to avoid certain boundary crossings (and to avoid certain multiple relationships) would in fact be harmful to the client and to the psychotherapy relationship. As Lazarus (1994) points out, this rigid approach often results in “artificial boundaries that serve as destructive prohibitions and thereby undermine clinical effectiveness” (p. 255). Numerous examples are cited in the relevant literature such as a refusal to touch a grieving client, the refusal to accept a small holiday gift from a child client, and refusing ever to self-disclose to a client out of a misguided fear that doing so might lead to an inappropriate multiple relationship. Such actions are not only misguided, they frequently are not even possible to enforce. For example, psychotherapists engage in various forms of self-disclosure all the time. The way psychotherapists dress, the jewelry one wears (to include an engagement ring or wedding band), the accent with which one speaks, and the physical manifestations of pregnancy are all types of self-disclosure (Zur, 2007). To suggest that a psychotherapist might avoid all self-disclosure is unrealistic. Of course, a distinction can be made between these inadvertent forms of selfdisclosure and the intentional disclosure of personal feelings toward a client. Yet, with attention to the guiding principles described earlier, self-disclosure (and all boundary crossings, for that matter) may be appropriately engaged in, and without fear of stepping onto a slippery slope that will inevitably lead to sexually intimate behavior with a client.
Sexual Attraction and Behaviors It is widely accepted that psychotherapists experience feelings of sexual attraction toward clients and engage in sexual fantasies about clients (Pope, Tabachnick, & Keith-Spiegel, 1987; Pope, Sonne, & Greene, 2006). This is a naturally occurring phenomenon that exists whether or not it is acknowledged and appropriately addressed. In fact, Pope, Tabachnick, and Keith-Spiegel (1986) found that 87% of psychotherapists they surveyed acknowledged having been sexually attracted to one or more clients. The issue of sexual feelings or attraction toward clients is one that has not received significant attention in the relevant literature and one that frequently is not addressed openly in the training of psychotherapists, be it in the academic setting or in clinical supervision. Pope and Tabachnick (1993) report that the majority of psychologists they surveyed report that their training in graduate school about these issues was poor or nonexistent. As a result, psychotherapists are often ill-prepared to respond to these feelings in a healthy, adaptive, and clinically appropriate manner. As Pope, Tabachnick, and Keith-Spiegel (1986) note, psychotherapists often respond to the experience of sexual attraction toward clients with feelings of guilt, shame, and confusion. As a result, many psychotherapists will minimize or avoid addressing their sexual attraction toward clients, possibly missing the opportunity to consider important clinical issues that are relevant to the client’s treatment. Additionally, this avoidance may create discomfort and anxiety on the part of the psychotherapist that the client may perceive, resulting in confusion or discomfort for the client that may adversely impact the psychotherapy relationship and process. Pope et al. (2006) address how the experience of sexual feelings toward or fantasies about clients is for many psychotherapists inconsistent with the view they hold of themselves as caring professionals. An acknowledgement of these feelings may create dissonance for the psychotherapist who must reconcile these very personal feelings with their professional role, image, and obligations. What often appears to be easiest is to push these feelings aside, avoiding addressing their existence and presence. These authors acknowledge that for many years, sexual feelings toward clients and sexual fantasies about clients have been taboo topics within the mental health professions. Students and supervisees may perceive their instructors’ and supervisors’ discomfort with openly addressing these topics. In addition to leaving trainees ill-prepared for appropriately responding to these experiences, it may contribute to the development of the shame, guilt, and anxiety that so many psychotherapists experience in response to these feelings (Ladany, Klinger, & Kulp, 2011). Pope et al. (2006) raise the possibility that psychotherapists may avoid addressing these naturally occurring feelings of attraction toward clients out of a fear of acting on them. Psychotherapists may view the acknowledgement of these feelings as a first step down the slippery
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slope that will lead them to engaging in sexual activity with clients. Rather than openly addressing and working to understand the clinical significance of these feelings in clinical supervision, psychotherapists may avoid addressing them out of shame or embarrassment, or in the na¨ıve hope that denying their existence will somehow cause these uncomfortable feelings to cease to exist. There is a clear difference between feeling attracted to a client and engaging in sexual behaviors with a client. Yet, these two topics seem inextricably linked and a potential source of confusion for many psychotherapists. While all psychotherapists who engage in sexual behaviors with clients first experience sexual attraction to these clients, only a very small percent of psychotherapists who experience sexual attraction to clients ever act on this attraction and engage in sexually intimate relations with clients. While more research is needed to better understand the link between these two phenomena, it is evident that avoidance, denial, and minimization are not likely to assist psychotherapists to effectively make sense of and appropriately manage these feelings.
Underlying Causes A number of reasons may be postulated for why psychologists may engage in boundary violations and inappropriate multiple relationships, to include sexually intimate relations with clients. These include naivety, problems with professional competence, and character issues.
Naivety The na¨ıve psychologist is one who may be uneducated, uninformed, or unaware of issues relevant to boundaries, multiple relationships, sexual feelings and fantasies, the slippery slope, standards of practice, and ethical decision making. While training in ethics is a requirement of APAaccreditation for doctoral programs in psychology, it is not known how much focus is placed on these issues. As has been reviewed, many psychologists report inadequate attention to these issues during their training. Failure to openly discuss feelings of physical or sexual attraction in clinical supervision adds to the risk of a na¨ıve approach to addressing these issues when one leaves graduate school and enters clinical practice. Psychotherapists may also be na¨ıve about their ability to control, deny, or independently manage their feelings of attraction toward clients. Instead of openly discussing and processing these feelings in clinical supervision or through consultation with trusted colleagues, they may naively believe that they can “handle it” or that if they ignore these thoughts and feelings they will just go away. Naivety about ethics standards and practices is never a justifiable excuse for engaging in inappropriate or unethical conduct. The APA Ethics Code (APA, 2010) makes this clear in stating that members must be aware of and follow the standards in the APA Ethics Code and that “lack of awareness or misunderstanding of an Ethical Standard is not itself a defense to a charge of unethical conduct” (p. 1). Yet a lack of awareness or understanding of the issues relevant to boundaries, multiple relationships, physical attraction to clients, ethics standards, ethical decision making, and sexual intimacies with clients can be seen as one possible explanation of how psychologists may engage in these behaviors.
Problems With Professional Competence It is widely accepted that the practice of psychotherapy is a demanding endeavor that places the clinician at risk for distress and burnout if ongoing challenges and stresses are not adequately managed (O’Connor, 2001). Psychologists must manage challenges and demands in both their professional and personal lives. Professional challenges may include difficult clients, clients who relapse or do not improve, clients who attempt or commit suicide, administrative and financial challenges, and others such as having clients with poor boundaries who act out sexually and test boundaries with the psychotherapist. Challenges in one’s personal life may include relationship difficulties, family illness, and financial stressors, as well as suffering from mental health difficulties such as depression, anxiety disorders, and substance abuse. Both sets of
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challenges interact and influence each other, often creating a level of distress that can adversely impact the psychologist’s decision-making abilities, judgment, and clinical competence (Barnett, 2008). While distress, burnout, and the impairment in professional judgment and functioning they may cause are not justifications for engaging in sexually inappropriate behaviors with clients, they often are contributing factors. As Smith and Fitzpatrick (1995) describe: To date, the most common profile to emerge is that of a middle-aged male therapist who is professionally isolated and is currently undergoing some personal distress or midlife crisis, often including marital problems. This so-called “lovesick” therapist typically begins his descent down the slippery slope by sharing his own problems and exposing his own vulnerability to a younger female client. (p. 504) Failure to proactively and effectively manage the stressors in one’s professional and personal lives, failure to engage in the ongoing practice of self-care to promote wellness, and a tendency to isolate oneself are all factors that may conspire to create conditions in which a psychotherapist may begin violating boundaries in an effort to get personal needs met through clients, greatly increasing the likelihood of inappropriate sexually intimate relations with clients occurring.
Character Issues It can be assumed that most individuals who enter the profession of psychology do so with good intentions. Yet there are those who, despite knowing their professional obligations and with forethought, choose to prey on the vulnerabilities of their clients and take advantage of them through sexually intimate behaviors. These professionals are described by Brayfield-Cave (1991) as “predators of the profession” (p. 7). While data on the percent of psychologists who fall into this category are not readily available, licensing board complaints, ethics committee complaints, and malpractice suit data indicate that such professionals do exist (Gottlieb & Younggren, 2009). This highlights the need for educators, trainers, and clinical supervisors to take very seriously their roles as gatekeepers of the profession, carefully monitoring students and trainees and not allowing those who appear unfit or unsuitable for the role of psychotherapist to enter into the profession (Johnson, Elman, Forrest, Rodolfa, & Schaffer, 2008). Also of great importance is the role of ethics committees and licensing boards. They must create and disseminate clear standards for sexually intimate behaviors and actively and uniformly enforce them.
Prevention and Positive Action There are numerous steps that can be taken to help minimize the risk of psychologists engaging in inappropriate sexual relations with clients. Knowledge of the APA Ethics Code and prevailing professional standards is an important first step, but as has been highlighted, psychotherapists must be cognizant of their own emotional needs and functioning, mindful of the power differential in the professional relationship, careful not to abuse their clients’ trust and dependence, and ever mindful of boundaries and multiple relationships. In doing so, it is very important to be self-aware and honest about when personal needs, vulnerabilities, and conflicts may be placing the psychologist at increased risk of violating boundaries. As Johnson, Barnett, Elman, Forrest, and Kaslow (2012) emphasize, psychologists, like other health professionals, are notoriously poor at self-assessing their competence and level of functioning, frequently overestimating their capabilities and underestimating their levels of distress and impairment. It is therefore of great importance that psychologists not isolate themselves professionally. Rather, consultation with colleagues should be seen as an essential element of each psychologist’s decision-making process when faced with questions about the appropriateness of planned actions and behaviors. It is further recommended that psychologists participate in ongoing peer consultation and support groups so that they will have a forum for openly discussing boundary and multiple relationship issues in a supportive environment where honest feedback may be received.
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When considering crossing boundaries with clients, it essential that each client’s individual differences be considered, to include presenting problems, treatment needs and challenges, personality pathology and history of boundary difficulties, and diversity issues relevant to understanding the potential impact of planned boundary incursions on the client. This recommendation is consistent with Lazarus’ (1994) admonition against rigid rules about boundaries and highlights the need for a deliberative approach in considering each potential boundary crossing. Psychologists who are educators, trainers, and clinical supervisors should openly discuss feelings of sexual attraction to clients with their students, trainees, and supervisees. The existence of these feelings needs to be normalized to minimize shame and the resulting avoidance of proactively addressing these feelings. Additionally, psychologists-in-training should be educated about boundaries, multiple relationships, and their responsibility to act based on a primary focus on each client’s best interests. Both psychologists-in-training and practicing psychologists should consider participation in personal psychotherapy when sexual feelings and fantasies about clients are preoccupying them and interfere with effective clinical practice. Additionally, when concerns about maintaining objectivity and judgment exist and when a risk of exploitation arises, personal psychotherapy for the clinician should be considered to address and work through underlying issues that may be creating the risky situation. When faced with ethical dilemmas, situations with no clearly evident right or wrong answer, it is important to utilize an ethical decision-making process to reason through the situation so that the best possible decision can be made. Younggren and Gottlieb (2004, pp. 256–257) suggest asking the following questions to aid in making decisions about potentially inappropriate actions with clients: (a) Is entering into the secondary relationship necessary, or should I avoid it? (b) Can the multiple relationship potentially cause harm to the client? (c) If harm seems unlikely or avoidable, would the additional relationship prove beneficial? (d) Is there a risk that the secondary relationship could disrupt the therapeutic relationship? (e) Can I evaluate this matter objectively? Additionally, when considering boundary incursions psychologists should consider their motivations and whose needs are being met, the relevance of the planned action to the client’s treatment needs and plan, if they are comfortable documenting the intended action and discussing it with colleagues, and if they have discussed the planned action with the client and considered his or her comfort and preferences. When considering posttermination intimate relationships with clients, psychotherapists are additionally advised to consider the requirements of Standard 10.08, Sexual Intimacies with Former Therapy Clients/Patients, of the APA Ethics Code (APA, 2010). Because these relations are typically so harmful and inappropriate, they are forbidden for 2 years from the date of last professional contact with the client. Then after this time period transpires, psychologists must consider the following seven factors when deciding on the appropriateness of entering the posttreatment sexual relationship to demonstrate that no exploitation is occurring: (1) the amount of time that has passed since therapy terminated; (2) the nature, duration, and intensity of the therapy; (3) the circumstances of termination; (4) the client’s/patient’s personal history; (5) the client’s/patient’s current mental status; (6) the likelihood of adverse impact on the client/patient; and (7) any statements or actions made by the therapist during the course of therapy suggesting or inviting the possibility of a posttermination sexual or romantic relationship with the client/patient. (p. 13)
Case Illustration Dr. Green is a 50-year old, male psychologist with over 25 years of solo private practice experience as a psychotherapist. His practice focuses on the treatment of depression, anxiety, and stressrelated difficulties in adults. Dr. Green has been married for over 20 years, but in recent months he has grown dissatisfied with his relationship, feeling alienated from his wife, viewing her as unsympathetic to the stressful nature of his work, and often preoccupied with and focused
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on her own issues. Dr. Green feels under pressure financially and is resentful of the money his wife spends on clothing, leisure time activities, and decorating their home. Dr. Green has found himself withdrawing from his wife emotionally, working longer hours, and, most recently, stopping off at a local restaurant for one or two alcoholic drinks before coming home in the evening to eat dinner alone, read, and then fall asleep. Dr. Green has also recently been spending time thinking about an attractive female client, Sharon Jones, both when out of the office and while meeting with other clients. He finds that he greatly enjoys their sessions and finds her to be a very interesting individual. Their insession discussions have recently ventured beyond her treatment issues of feelings of loneliness and general relationship dissatisfaction, with Dr. Green finding himself having a great deal in common with her. At times, Dr. Green shares about their common interests during their sessions. Between sessions he finds himself fantasizing about what a relationship with Ms. Jones would be like, but dismisses these thoughts, saying to himself that this would never happen. This week, one evening after work when he enters the restaurant, Dr. Green notices Ms. Jones sitting at the bar having a drink. She notices him walking in, makes eye contact, and waves hello. Not wanting to be rude, Dr. Green walks over and greets her. As they chat, he sits down next to her and then orders his drink. As they continue speaking about how their day went, common interests, and the like, Dr. Green becomes aware of how enjoyable this is. They talk, laugh, and drink together, at times casually touching each other on the forearm when agreeing with something the other has said.
Discussion Dr. Green fits the general description of the “lovesick therapist” described earlier (Smith & Fitzpatrick, 1995). He is an older male who is interacting with an attractive, younger female client. He is experiencing feelings of alienation and lack of emotional support in his marriage and appears to be getting some of his emotional needs met through his interactions with his client. This occurs first during treatment sessions when he expands discussions beyond the client’s treatment needs and ventures into sharing about their common interests. Dr. Green also finds himself thinking of this client during work and away from the office, but seems unaware of this as a sign that closer examination of the situation is needed. Dr. Green appears to be isolated personally and professionally. Rather than work with his wife to address the issues in their relationship and his feelings of lack of support, appreciation, and understanding, he has been withdrawing from her further by spending more time at work and using alcohol as a means of responding to and coping with these difficulties. With regard to his preoccupation with his client, there is no acknowledgement of any concerns about this, his fantasies about her (to include when in session with other clients), how he is coping with the stresses in his life, or that his objectivity or judgment may in any way be becoming increasingly impaired. Rather, Dr. Green appears to be getting some of his emotional needs met through his relationship with Ms. Jones, a relationship that has been increasingly shifting from a professional one to a more personal one.
Analysis and Recommendations Based on the information provided, it appears that Dr. Green is well on his way down the slippery slope, perhaps moving rapidly toward entering an intimate relationship with Ms. Jones: Dr. Green is isolated personally and professionally; he has not taken actions to address the stresses and frustrations in his personal life; he is using the relationship with a client to meet his own emotional needs; and he has failed to consider how the changes in the relationship with Ms. Jones may be adversely impacting his objectivity and judgment, and how they may be harmful to Ms. Jones over time. Upon noticing himself feeling attracted to Ms. Jones and becoming preoccupied with thoughts about her, Dr. Green should have sought out consultation with an experienced colleague and perhaps even have sought out ongoing clinical supervision from a colleague with expertise in boundary issues and multiple relationships. Through this consultation and supervision, Dr.
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Green could openly discuss all the details relevant to life circumstances, feelings, fantasies, and desires. With this colleague, decisions could be made about the appropriateness of continuing Ms. Jones’ psychotherapy, if referring her to another professional would be in her best interest, if personal psychotherapy for Dr. Green would be appropriate (to include addressing his use of alcohol), and if marriage counseling would be appropriate for Dr. Green and his wife. Further, it is hoped that Dr. Green would receive education about boundaries and multiple relationships in psychotherapy, how feelings of attraction to clients should be addressed, and how ongoing challenges and stresses in his personal life can impact his professional functioning and should be addressed.
Conclusions Boundaries and multiple relationships are complex issues that if not addressed and managed appropriately, can lead to harm to clients. While sexually intimate relations with clients are widely accepted as inappropriate and harmful to clients, psychologists who do not take appropriate precautions and do not engage in a thoughtful decision-making process may find themselves acting in ways that are inconsistent with the ethics standards of the profession and place clients at significant risk of exploitation and harm. While no rigid rules exist for managing boundaries and multiple relationships, relevant factors to consider have been reviewed and recommendations for ethical practice have been made. With thoughtful attention to clients’ needs and best interests, prevailing professional standards, ethical decision making, personal needs and stressors, and education about these issues, it is hoped that psychologists will successfully navigate these challenges in a manner consistent with the highest ethics standards of the profession.
Selected References and Reading Recommendations American Psychological Association. (2010). Ethical principles of psychologists and code of conduct. Retrieved from http://www.apa.org.ethics Barnett, J. E. (2008). Impaired professionals: Distress, professional impairment, self-care, and psychological wellness. In M. Herson & A. M. Gross (Eds.), Handbook of clinical psychology (Vol. 1, pp. 857–884). New York: John Wiley & sons. Barnett, J. E., Lazarus, A. A., Vasquez, M. J. T., Morehead-Slaughter, O., & Johnson, W. B. (2007). Boundary issues and multiple relationships: Fantasy and reality. Professional Psychology: Research and Practice, 38(4), 401–410. Brayfield-Cave, S. (1991). Sexual predators in the profession. Register Report, 17, 7–8. Gabbard, G. O. (1989). Sexual exploitation in professional relationships. Washington, DC: American Psychiatric Association. Gottlieb, M. C., & Younggren, J. N. (2009). Is there a slippery slope? Considerations regarding multiple relationships and risk management. Professional Psychology: Research and Practice, 40(6), 564–571. Gutheil, T. G., & Gabbard, G. O. (1993). The concept of boundaries in clinical practice: Theoretical and risk management dimensions. American Journal of Psychiatry, 150, 188–196. Johnson, W. B., Barnett, J. E., Elman, N., Forrest, L., & Kaslow, N. J. (2012). The competent community: Toward a radical reformulation of professional ethics. American Psychologist, 67(7), 557–569. Johnson, W. B., Elman, N. S., Forrest, L., Robiner, W. N., Rodolfa, E., & Schaffer, J. B. (2008). Addressing professional competence problems in trainees: Some ethical considerations. Professional Psychology: Research and Practice, 39(6), 589–599. Knapp, S. J., & VandeCreek, L. D. (2012). Practical ethics for psychologists: A positive approach (2nd ed.). Washington, DC: APA Books. Ladany, N., Klinger, R., & Kulp, L. (2011). Therapist shame: Implications for therapy and supervision. In R. L. Dearing & J. P. Tangney (Eds.), Shame in the therapy hour (pp. 307–322). Washington, DC: American Psychological Association. Lazarus, A. A. (1994). How certain boundaries and ethics diminish therapeutic effectiveness. Ethics & Behavior, 4, 255–261. Lazarus, A. A., & Zur, O. (Eds.) (2002). Dual relationships and psychotherapy. New York: Springer.
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O’Connor, M. F. (2001). On the etiology and effective management of professional distress and impairment among psychologists. Professional Psychology: Research and Practice, 32(4), 345–350. Pope, K. S., Keith-Spiegel, P., & Tabachnick, B. G. (2006). Sexual attraction to clients: The human therapist and the (sometimes) inhuman training system. Training and Education in Professional Psychology, S(2), 96–111. Pope, K. S., Sonne, J. L., & Greene, B. (2006). What therapists don’t talk about and why: Understanding taboos that hurt us and our clients. Washington, DC: American Psychological Association. Pope, K. S., & Tabachnick, B. G. (1993). Therapists’ anger, hate, fear, and sexual feelings: National survey of therapist responses, client characteristics, critical events, formal complaints, and training. Professional Psychology: Research & Practice, 24, 142–152. Pope, K. S., Tabachnick, B. G., & Keith-Spiegel, P. (1986). Sexual attraction to clients: The human therapist and the (sometimes) inhuman training system. American Psychologist, 41, 147–158. Pope, K. S., Tabachnick, B. G., & Keith-Spiegel, P. (1987). Ethics of practice: The beliefs and behaviors of psychologists as therapists. American Psychologist, 42, 993–1006. Pope, K. S., Tabachnick, B. G., & Keith-Spiegel, P. (1988). Good and poor practices in psychotherapy: National survey of beliefs of psychologists. Professional Psychology: Research and Practice, 19(5), 547– 552. Smith, D., & Fitzpatrick, M. (1995). Patient–therapist boundary issues: An integrative review of theory and research. Professional Psychology: Research and Practice, 26(5), 499–506. Sonne, J. (2013). The “vicissitudes of love” between therapist and patient: A review of the research on romantic and sexual feelings, thoughts, and behaviors in psychotherapy. Journal of Clinical Psychology, 70(2), 182–195. Younggren, J. N., & Gottlieb, M. C. (2004). Managing risk when contemplating multiple relationships. Professional Psychology: Research and Practice, 35(3), 255–260. Zur, O. (2007). Boundaries in psychotherapy. Washington, DC: American Psychological Association.
