This month I would like to take the opportunity to summarize and present some of the important aspects of a workshop I recently attended on the subject of sexual boundary violations in psychotherapy. The presenter, Andrea Celenza, is a psychologist and psychoanalyst with a national reputation on the subject of sexual boundary violations. She is author of Sexual Boundary Violations: Therapeutic, Academic, and Supervisory Contexts, published in 2007 by Jason Aronson. She has been involved in clinical research on the subject, and has worked extensively with both victims and perpetrators of such boundary violations, and clearly demonstrated her expertise and knowledge of this very important issue.

I am taking the time to present some of this information here because I believe it is central to the concerns of our training program. It is my opinion that this issue warrants more explicit discussion and attention in our training program (not just ours, obviously, but all such training programs) for a number of reasons.

First, Celenza points out that all the research done in this area strongly suggests the frequency of such boundary violations is far greater than we might like to think, with numbers ranging from 4% to 25% of therapists (depending on sex of therapist and study) reporting that they have at least once had sexual contact with a patient. The numbers for supervisors and instructors in various clinical settings is even higher - though Celenza was quick to point out some of the relevant differences from the therapy situation. Those numbers seem to vary a great deal, but a large part of the difference has to do with the sex of the therapist. Female therapists report significantly less occurrences than male therapists, who account for the numbers in the 20% range. That means that approximately 1 in 5 male therapists in the studies reported having committed at least one such sexual boundary violation.

Celenza notes that these two apparently irreconcilable responses both lead to a similar sequestering of the issues and the individuals involved. The assumption that such boundary violations are usually repetitive and involve psychopathic individuals is contradicted by the research data. While there are clearly predatory individuals that repeatedly violate sexual boundaries with patients, the large majority of individuals who have reported sexual contact with a patient report having had such contact with only a single patient. Celenza reports that there is great diagnostic diversity in this group of therapists.

Rather than pathologizing a majority of those who commit such boundary violations, Celenza has sought to understand and interpret the factors surrounding such events. In fact, one of the major conclusions Celenza reports is that the idea that "it could never happen to me" is problematic. She identifies a number of factors that seem to be precursors to such boundary violations, and in many instances, these are situational, or involve some interaction of situational stressors and personality characteristics of the therapist. But here is the thing: those personality characteristics, such as being identified with vulnerability and need, caretaking, harboring covert rescue fantasies, are the very same psychological characteristics that bring many - if not most - of us into our chosen profession. Contrary to the long-preferred dis-identification with perpetrators of boundary violations, Celenza argues that it is, for at least a large subset of transgressors, "an occupational hazard."

The implications of her perspective are very important. She highlights the notion that therapist self-care is essential to prevention of sexual boundary violations. Working too much, isolation in one's practice, lack of social contact, lack of intimacy and loving connection in one's personal life, and the presence of stressful life circumstance are risk factors. Lack of adequate supervision may contribute to problematic elements in the therapy process, such as transforming countertransference hate to countertransference love.

Celenza recommends a number of attitudinal changes that she believes are necessary if we are to meaningfully address this problem. She stresses the need for an atmosphere of openness, honesty and support, including support networks for victims, and the recognition of the universality of fallibility. There is a need also for institutional changes, with responsiveness to such problems that seeks out a meaningful middle ground between judgment on the one hand and denial on the other. Celenza notes that the threat of punishment, including legal and administrative threats, are responsible at least in part for the secrecy with which such matters are often dealt with (or not dealt with). She argues for the importance of rehabilitation as opposed to punishment, at least with the large group of one-time transgressor.

Other institutional support may include the role of a senior and trusted analyst in the community who may serve as a kind of ombudsperson, without the administrative requirements of an ethics committee. Celenza also recommends the implementation of a Peer Relations Committee whose function is to provide support, guidance and assistance to therapists in need.

I would like to suggest that CPPNJ develop our institutional awareness of this problem, which the research suggests is very much "an occupational hazard."  It is my hope that doing so will enable us to sustain a meaningful dialogue necessary to develop the institutional capacity to respond appropriately and constructively to incidents of such boundary violations, and to offer training and leadership in the area of sexual boundary violations both for our own membership and for the larger mental health community. Anyone interested in working on this project should feel free to contact me. 

Seth