Therapist - Client Sexual Relationships ... The Problem is Real.

For Brutus, as you know, was Caesar's angel
Judge, O you gods, how dearly Caesar loved him!
This was the most unkindest cut of all;
For when the noble Caesar saw him stab,
Ingratitude, more strong than traitors' arms,
Quite vanquish'd him: then burst his mighty heart;

William Shakespeare, “Julius Caesar, Act III, Scene 2”

Of the many hurdles, obstacles and life-threatening issues confronting persons suffering from severe eating disorders, being mentally, emotionally or sexually exploited by the very person from whom they seek help, guidance and sometimes even salvation truly is “the most unkindest cut of all.” It would be easy to dismiss reported incidents of therapists taking advantage of their patients as isolated and rare. Persons may argue that proven instances are so rare that they do not constitute a grave issue worth consideration and as such, we would be seeking to find a solution to a problem that does not really exist. You maintain these false beliefs at your peril.

Studies on Prevalence and Addressing the Issue

In 1991, Kenneth Pope published the definitive research study on “Prior Therapist – Patient Sexual Involvement Among Patients Seen by Psychologists[1].” The findings of this study were shocking. The study found, “A national survey of 1,320 psychologists found that half the respondents reported assessing or treating at least one patient who had been sexually intimate with a prior therapist; a total of 958 sexual intimacy cases were reported. Most cases involved female patients; most involved intimacies prior to termination; and most involved harm to the patient. Harm occurred in at least 80% of the instances in which the therapists engaged in sex with a patient after termination. Respondents reported that in only about 4% of the 1,000 cases in which the issue of sexual intimacies arose, the allegations were false.”

Other significant findings discovered and published by Pope include the following:

“1. It is crucial to note that the sole national study using the same instrument during the same time period with the three major mental health professionals found no significant difference among the rates at which psychiatrists, psychologists, and social workers acknowledged engaging in sex with their patients (Borys & Pope, 1989). 

2. Female patients were more likely to experience harm if the intimacy was initiated before termination (95%) than after (80%), while male patients were not more likely to experience harm from intimacies initiated before termination (80%) than after (86%).”

With regard to implementing processes to lessen the likelihood of this sexual exploitation, Pope and his team also submitted some very damning hypothesis and data. To this end, Pope’s study stated:

We need to reexamine the opportunities for preventing sexual exploitation of patients. To some extent this may involve increased understanding of the tendency of most therapists to experience sexual attraction to patients (Pope, Keith-Spiegel & Tabachnick, 1986; Pope, Sonne, & Holroyd, 1993) and the phenomenon of engaging in sexual fantasies about patients (Pope et al., 1986; Pope, Tabachnick & Keith-Spiegel, 1987). It may also involve increased understanding of the sexualization of our teaching relationships and the ways in which training programs provide education and modeling regarding sexual issues (Glaser & Thorpe, 1986; Pope, Levenson & Schover, 1979; Robinson & Reid, 1985; Tabachnick, Keith-Spiegel & Pope, 1991). What seems likely, however, is that creating, implementing, and evaluating comprehensive and effective prevention efforts will not come easily for us as clinicians. As much as we may talk about the concept, it is hard to argue with Sarason's (1985) conclusion: "The fact is that in practice, and the ways clinicians are prepared for practice, the preventive stance is conspicuous by its absence" (p. 63). And yet as psychologists, we have a rich and growing legacy of theory, research, and experience in attempting to bring about the kind of sustained, systematic changes that might be part of an effective prevention program (e.g., Bronfenbrenner, 1974; Cowen, 1977; Kelly & Hess, 1987; Sarason, 1972, 1988; Trickett, 1990). As we consider the feasibility and desirability of various preventive strategies, it is important that we also consider carefully their ethical implications (Bond & Albee, 1990; Trickett & Levin, 1990).

Based in part upon Pope’s study, the American Psychological Association enacted a number of ethical codes addressing this sexual exploitation. These guidelines include the following:

3.02 Sexual Harassment. Sexual harassment is unwanted/offensive sexual solicitation, physical advances, or conduct that is sexual in nature, which may be deemed abusive to another party. Psychologists avoid sexually harassing those with whom they work.

3.04 Avoiding Harm. Psychologists take reasonable steps to avoid/minimize harming their clients, students, supervisees, research participants, and others.

3.05 Multiple Relationships. A multiple relationship occurs when a psychologist is in both a professional and additional role with another person, with a person associated with the person with whom the psychologist has a professional relationship, or when he/she promises to enter into another relationship in the future with any of these persons. If such a dual relationship impairs objectivity and/or competence, or could potentially risk exploitation or harm to those who are served, the actions are deemed unethical.

3.08 Exploitative Relationships. Psychologists do not exploit persons over whom they have power/authority.

7.07 Sexual Relationships with Students and Supervisees. Psychologists do not engage in sexual relationships with those over whom they have evaluative authority.

10.01 Informed Consent to Therapy. This is pertinent to the nature of therapy, so that clients have realistic expectations; the therapeutic relationship is a professional one, which should be made explicit to clients at the outset.

10.05 Sexual Intimacies with Current Therapy Clients/Patients. Psychologists must not engage in sexual intimacies with current therapy clients.

10.06 Sexual Intimacies with Relatives or Significant Others of Current Therapy Clients/Patients. Psychologists must not engage in sexual intimacies with relatives or significant others of current therapy clients.

10.07 Therapy with Former Sexual Partners. Psychologists must not conduct therapy with former sexual partners.

10.08 Sexual Intimacies with Former Therapy Clients/Patients. Psychologists must not engage in sexual intimacies with former therapy clients for at least two years after cessation or termination of therapy. After this interval, psychologists can potentially, albeit infrequently, become exempted from this principle if they demonstrate that no client exploitation occurred in the following areas: the amount of time that has passed since therapy terminated; the nature, duration, and intensity of the therapy; the circumstances of termination; the client’s/patient’s personal history; the client’s/patient’s current mental status; the likelihood of adverse impact on the client/patient; and any statements or actions made by the therapist during the course of therapy suggesting or inviting the possibility of a post-termination sexual or romantic relationship with the client/patient (American Psychological Association, 2002 American Psychological Association. (2002). Ethical principles of psychologists and code of conduct. American Psychologist, 57, 1060–1073. Adrian, C. (1996). Therapist sexual feelings in hypnotherapy: Managing therapeutic boundaries in hypnotic work. International Journal of Clinical and Experimental Hypnosis, 44, 7–19. , 2010 American Psychological Association. (2010). 2010 amendments to the 2002 ethical principles of psychologists and code of conduct. American Psychologist,65, 493.[Crossref], [PubMed], , [Google Scholar]).

In 2016, the statistics and harmful ramifications were reiterated in an article authored by Michael R. Capawana, PhD, who has privileges at Massachusetts General Hospital and published in the Journal of Cogent Psychology, Volume 3, Issue 1 (2016). In his article, “Intimate Attractions and Sexual Misconduct in the Therapeutic Relationship: Implications for Socially Just Practice[2],” Dr. Capawana stated:

Sexual contact between therapists and clients is unethical due to the power imbalance that permeates all aspects of the relationship, and because research has demonstrated that this form of sexual contact has ramifications for clients in the form of psychological damage (Sommers-Flanagan & Sommers-Flanagan, 2004 Sommers-Flanagan, J., & Sommers-Flanagan, R. (2004). Counseling and psychotherapy theories in context and practice: Skills, strategies, and techniques. Hoboken, NJ: Wiley. [Google Scholar]). Pope (2001Pope, K. (2001). Sex between therapists and clients. In J. Worell (Ed.), Encyclopedia of women and gender: Sex similarities and differences and the impact of society on gender (Vol. 2, pp. 955–962). Waltham, MA: Academic Press. [Google Scholar]) documented the most common reactions that are frequently associated with therapist–client sex, articulating them as comparable to outcomes of incest or rape. These reactions are: ambivalence; cognitive dysfunction; emotional lability; emptiness and isolation; impaired ability to trust; guilt; increased suicidal risk; role reversal and boundary confusion; sexual confusion; and suppressed anger (Pope, 2001Pope, K. (2001). Sex between therapists and clients. In J. Worell (Ed.), Encyclopedia of women and gender: Sex similarities and differences and the impact of society on gender (Vol. 2, pp. 955–962). Waltham, MA: Academic Press. [Google Scholar]). A majority of clients surveyed reported sex with therapists as damaging; even those who found it pleasurable at first, eventually viewed it as exploitative (Koocher & Keith-Spiegel, 2008 Koocher, G. P., & Keith-Spiegel, P. (2008). Ethics in psychology and the mental health professions (3rd ed.). New York, NY: Oxford University Press. [Google Scholar]).

Real Life Examples and Impact

We previously set forth the issues regarding Nicole P. Siegfried who has been with Castlewood/Alsana from April 2013 to present. In January 2018, Castlewood/Alsana named Ms. Siegfried as its Chief Clinical Officer. We disclosed that Castlewood offered employment to Ms. Siegfried while she was still on professional probation and under practice supervision for having an inappropriate sexual relationship with a patient. Five months after she was placed on professional probation, she began her employment with Castlewood and her misdeeds went largely undisclosed and unknown. And yet, that horse is at the glue factory and there is no reason to continue to beat it.

However most recently, on August 21, 2018, Michael Jacksa, a counselor at Timberline Knolls was arrested and charged with assaulting a 29 year old patient at Timberline Knolls during two counseling sessions between May and June of 2018. Jacksa was accused by patients of digitally penetrating their vaginas and buttocks, putting his hands beneath their clothing, fondling their breasts and forcing them to give him oral sex. During his first bond hearing on Aug. 21, Jacksa reportedly admitted to police that he "probably went too far."

This “probably went too far” conduct manifested itself by him being indicted for his reprehensible conduct directed toward a second victim. According to the new charges, between Dec. 1, 2017 and Jan. 10, 2018, Jacksa was treating an out-of-state woman for eating disorders, anxiety and past sexual abuse. The patient alleges that Jacksa sexually assaulted her during four therapy sessions at Timberline Knolls. The prosecutor said the second woman came forward after seeing media reports.

According to the prosecutor, at least six other former patients of Jacksa's from across the country have contacted the Lemont Police Department, stating that Jacksa allegedly engaged in "inappropriate sexual behavior" during their respective therapy sessions.

And therein lies the greater issue. More often than not, these instances are not isolated events, restricted to one person. More often than not, we are dealing with predators who repeatedly prey on the weak and the vulnerable. More often than not, these attacks are not about sex … they are about power, taking advantage of the weak and exploiting those most vulnerable knowing that they are less likely to get reported.

Unlike Castlewood, Timberline Knolls took immediate steps addressing the matter. They discharged Jacksa, stated that they performed a thorough background search on not only him, but on all employees and stated that they are cooperating with authorities. But, even this is not enough.

Address the Problem

As the many studies show, therapist – patient sexual involvement is not rare. And when it does happen, the damage and injury to the patient is very real, substantive and can be debilitating. It is long past time for the eating disorder industry to step to the plate and aggressively address this issue … before you are forced to do so by one of my brethren of the bar who represents one of the many victims.

First, this problem is tailor-made to be addressed by those programs in the Residential Eating Disorder Consortium. (“Consortium”). Last month, the Consortium published their new Standards of Excellence Project. (“STEP”). As part of this STEP project, they included the REDC Code of Ethics. A review of this Code of Ethics indicates with regard to this very real issue of therapist – patient sexual exploitation, the Consortium did not address this problem. This oversight must be rectified immediately.

Any attorney with any sense and experience would advise the Consortium to appoint a blue ribbon panel to address this problem; to come up with new standards and investigative techniques to increase the likelihood of finding predators who apply for and are offered jobs. Improve your interviewing standards and administer testing designed to increase the likelihood of discovering characteristics exhibited by predators who take advantage of our loved ones.

This issue is real. Our children are being exploited and harmed. The statistics and studies indicate that the problem is prevalent. It exists today. Improve your standards and pledge to employ only the best. Clean up your houses … or the court system will.

We entrust the most precious thing we hold dear … the very lives of our loved ones to the Consortium and other entities. And yet, the Consortium and these other entities are not “entitled” to that gift. It is a gift that must be earned each and every day. The duty is absolute and non-delegable. But, if the Consortium, its members or any other entity in the eating disorder industry fails at this task through neglect, avarice or sloth? 

The Bard, penned the line, “This was the most unkindest cut of all.” And yet, he also wrote, “Prick us do we not bleed? Tickle us do we not laugh? Poison us, do we not die? Wrong us, shall we not revenge.”

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[1] https://kspope.com/sexiss/sex2.php#copy

[2] https://www.tandfonline.com/doi/full/10.1080/23311908.2016.1194176