Download Therapist-Patient Sex as Sex Abuse: Six Scientific, Professional, and

Therapist-Patient Sex as Sex Abuse:
Six Scientific, Professional, and Practical
Dilemmas in Addressing Victimization and
Rehabilitation
Kennet h S . P ope
ABSTRACT: Psychology, like other mental health professions, has experienced
difficulty addressing the issue of therapist-patient sexual intimacies vigorously,
carefully, and effectively. Six fundamental challenges, based on frequently made
comparisons of therapist-patient sex to incest and rape, are identified as crucial in
addressing forms of sex abuse in which perpetrators are predominantly male and
victims are predominantly female: (a) acknowledging the scope of the
phenomenon, (b) affirming the notion and the mechanisms of accountability, (c)
assessing the validity of allegations, (d) evaluating the nature and validity of
research evidence, (e) overcoming perpetrator stereotypes and inclinations to
collude with or to enable sex offenders, and (f) confronting the notion of victim
responsibility.
One of the first, most persistent psychologists urging the profession to confront and
eliminate therapists' sexual abuse of patients was Keith-Spiegel (1977), who noted the
ineffectiveness of appealing to perpetrators and potential perpetrators on the basis of a
professional ethic of avoiding harm to patients or an ethic of refraining from sexual abuse
of women. She reframed the issue to appeal more to self-interest, providing "ten reasons
why [sex with clients] is a very stupid thing to do." Her focus was "not on the devastation
that may result for the client ... but on what ensues for the psychologist" (p. 1).
Despite such concern, however, sexual abuse of patients continues. The thesis of my
article is that psychology's difficulties confronting the sexual abuse of (mostly female)
patients by (mostly male) therapists parallel earlier professional attempts to address forms
of sexual abuse, such as rape and incest, in which the perpetrators are predominantly
male and the victims are predominantly female. This parallel implies that effectively
addressing sex abuse requires a careful, informed, and reasoned response to at least six
fundamental challenges, which are discussed in the following sections.
Three considerations are important in providing a context for the following discussion.
First, comparing therapist-patient sexual intimacies with other forms of sex abuse is by
no means an original idea; numerous clinicians and researchers have analyzed the various
ways (e.g, in terms of dynamics, characteristics of perpetrators, uses of power, lack of
genuine consent, and consequences for victims) in which sexual intimacies with patients
are similar to rape and incest (e.g., Bailey, 1978; Barnhouse, 1978; Bates & Brodsky,
1989; Borys, 1988; Burgess, 1981; Chesler, 1972; Connel & Wilson, 1974; Dahlberg,
1970; Finkelhor, 1984 ; Freud, 1915/1983; Gabbard, 1989; Gilbert & Scher, 1989;
Herman, Gartrell, Olarte, Feldstein, & Localio, 1987; Kardener, 1974; Kavoussi &
Becker, 1987; Maltz & Holman, 1984; Marmor, 1972; Masters & Johnson, 1976; Pope &
Bouhoutsos, 1986; Redlich, 1977; Russell, 1986; Saul, 1962; Searles, 1959; Siassi &
Thomas, 1973; A. A. Stone, 1990; L. G. Stone, 1980; M. Stone, 1976).
Second, it is possible for some therapists to argue from a variety of perspectives that
therapist-patient sexual intimacies are in no way abusive (e.g., that sexual intimacies do
not usually cause great harm to patients and are generally inconsequential or beneficial;
that such intimacies do not constitute an abuse of trust, power, prerogative, responsibility,
or the therapeutic relationship). Even (or especially) in light of such arguments, it may be
heuristically useful to examine ways in which professional responses to therapist-patient
sex may be similar to responses to rape and incest. All three phenomena present us with
difficult dilemmas. The response to these dilemmas may play a crucial role in the
continuing development of our profession's scientific integrity and ethical character.
Third, it is crucial to emphasize that psychologists do not--at least in light of the most
recent research--engage in such abuse at higher rates than do members of the other
mental health professions. In the most recent national survey of 4,800 therapists, Borys
and Pope (1989) found that psychiatrists, psychologists, and clinical social workers
engaged in sexual intimacies with their patients at equivalent rates.
Acknowledging the Scope of the Phenomenon
The first challenge is to acknowledge the existence and scope of the behavior.
Historically, forms of sexual abuse such as rape and incest have, until relatively recently,
received little attention and were thought to involve very few people (Courtois, 1988 ;
Estrich, 1987; Herman, 1981; National Institute of Law Enforcement and Criminal
Justice, 1975; Russell, 1986; C. E. Walker, Bonner & Kaufman, 1988). Less than 40
years ago, for example, a scholarly volume stated that there were about one or two cases
of incest each year for each million U.S. citizens (Weinberg, 1955). More recently, the
Comprehensive Textbook of Psychiatry placed the incidence rate at between 1.1 and 1.9
per million ( Henderson, 1975). Likewise, rape was generally ignored or neglected -Amir (1971) was unable to find even one book devoted exclusively to the topic -- and as
late as the early 1970s, rape accusations were generally viewed as "lies or fantasies"
(Estrich, 1987, p. 43).
Charges of sex abuse were thus generally attributed to an assumed innate female
tendency to make false allegations of a sexual nature against innocent men. It is possible
that this attribution gained popularity from Freud's renunciation of his "seduction theory".
"When girls who bring forward this event [incest] in the story of their childhood fairly
regularly introduce the father as the seducer, neither the phantastic character of this
accusation nor the motive actuating it can be doubted" (Freud, 1924/1952, p. 379). The
assumed motive is female sexuality and a female desire for an incestuous relationship
with the father (p. 379).
The 1970 edition of Wigmore's authoritative text on legal evidence exemplifies the
degree to which the legal and psychiatric professions accepted the view that almost all
charges of sex abuse reflect an inherent female tendency both to make false accusations
and to fantasize about being raped. Wigmore stated authoritatively that
chastity may have a direct connection with veracity, viz. when a woman or young girl
testifies as complainant against a man charged with a sexual crime-rape, rape under age,
seduction, assault. Modern psychiatrists have amply studied ... girls and women coming
before the courts in all sorts of cases. Their psychic complexes are multifarious, distorted
partly by inherent defects, partly by diseased derangements or abnormal instincts, partly
by bad social environment, partly by temporary physiological or emotional conditions....
The unchaste (let us call it) mentality finds incidental but direct expression in the
narration of imaginary sex incidents of which the narrator is the heroine or the victim... .
No judge should ever let a sex offense go to the jury unless the female complainant's
social history and mental makeup have been examined and testified to by a qualified
physician.... The reason I think that rape in particular belongs in this category is one well
known to psychologists, namely, that fantasies of being raped are exceedingly common in
women, indeed one may almost say that they are probably universal. (Wigmore,
1934/1970, pp. 745-746)
The sexual abuse of patients similarly received little attention until the recent past.
Although the prohibition has been found in sources as diverse as the 2, 500-year-old
Hippocratic Oath and the even earlier code of the Nigerian healing arts (Brodsky, 1989),
the professional literature failed, for the most part, to address even the possibility that a
number of professionals were violating this ancient prohibition (Keith-Spiegel &
Koocher, 1985; Pope & Bouhoutsos, 1986). As late as 1977, Davidson could term sexual
intimacies with patients the "problem with no name."
At times, there has been active resistance to collecting or publishing data showing the
scope and consequences of such abuse. More than 25 years ago, H. Greenwald (cited by
Shepard, 1971) tried to encourage systematic study of therapist-patient sexual intimacies:
I just raised the questions ... intending, as a clinical psychologist, that it be studied like
any other phenomenon. And just for raising the question, some members circulated a
petition that I should be expelled from the Psychological Association. (p. 2)
In the late 1960s, B. Forer, having obtained the approval of the Los Angeles County
Psychological Association and the Los Angeles Society of Clinical Psychologists to
survey their memberships, undertook the first systematic study of the phenomenon in the
United States. To the dismay of both organizations, his findings indicated a relatively
high rate of sexual intimacies between members and their patients. On October 28, 1968,
having reviewed his research data with organizational leadership, the Board of Directors
decided to prohibit disclosing the findings either at professional conventions or through
journal publication (an interesting decision in light of the mandate of the American
Psychological Association's [APA's] Ethical Principle 1 a that psychologists never
suppress data disconfirming their favored hypotheses; APA, 1981 ), maintaining that it
was "not in the best interests of psychology to present it publicly" (B. Forer, personal
communication, November 1984; see also Forer, 1980).
Active resistance to disclosure of studies suggesting that therapists have been sexually
abusing their patients was by no means limited to the psychology profession. In the
introduction to his article "Sexual Contact Between Patient and Therapist, " a prominent
psychiatrist noted "I have had trouble getting this paper accepted by larger organizations
where I had less, but still not inconsiderable, influence. I was told that it was too
controversial" (Dahlberg, 970, p. 107). Gechtman (1989) discussed evidence that
resistance to the publication of such data still remains exceptionally strong among social
work organizations.
The first article drawing inferences from systematically collected data regarding the
phenomenon of therapist-patient sexual intimacies in psychology appeared in American
Psychologist in 1971. After analyzing 10 years of insurance carrier data regarding
malpractice complaints filed against psychologists, Brownfain (1971) concluded
that the greatest number of [all malpractice] actions are brought by women who lead lives
of very quiet desperation, who form close attachments to their therapists, who feel
rejected or spurned when they discover that relations are maintained on a formal and
professional level, and who then react with allegations of sexual improprieties. (p. 651)
He mentioned no case during this 10-year period in which a patient's claims of sexual
intimacies with her therapist were considered to be truthful.
Two years later, the American Journal of Psychiatry published data, based on a survey of
the male members of the Los Angeles County Medical Society, suggesting that at least
some therapists (about 10% of the psychiatrists) had in fact engaged in sex with one or
more patients (Kardener, Fuller, & Mensch, 1973). The format of this survey formed the
basis for the first national incidence study of therapist-patient sex, a study undertaken by
two psychologists (Holroyd & Brodsky, 1977). They found, on the basis of a 70% return
rate, that 11% of the male therapists and 2% of the female therapists reported engaging in
erotic contact with at least one patient and that 80% of those therapists did so with more
than one patient. Their work constituted a landmark in the profession's acknowledgment
that a number of therapists were actually engaging in sexual intimacies with their
patients. Numerous research studies followed (for reviews of this literature, see Gabbard,
1989 ; Pope, 1990; Pope & Bouhoutsos, 1986). Research and theory were brought to bear
on the fact that the intimacies were frequently initiated after termination, a factor that,
like initiating the intimacies outside of the office or only with patients who were "mature,
" made them no less abusive or harmful (Brown, 1988; Ethics Committee of the APA,
1988; Gabbard & Pope, 1989; Pope, 1988; Vasquez, in press). The sexual abuse of
patients could no longer continue as the "problem with no name", it is increasingly
difficult to dismiss virtually all accusations as groundless, as the expression of individual
psychopathology or of some innate female tendency to make false sex charges against
men. Like rape, incest, and other forms of sexual abuse, sexual abuse of patients is no
longer invisible.
Professional Accountability
Having acknowledged that some therapists have been engaging in sexual intimacies with
people who have come to them for help, we must determine the degree to which we are
willing to affirm and support actively and effectively the long-standing prohibition
against the practice and to hold ourselves genuinely accountable for violating the
prohibition. It has been suggested that one of the primary reasons that health care
professions have experienced such difficulty responding realistically and effectively to
rape and incest is that the populations both of perpetrators and of health care
professionals have historically been predominantly male (e.g., Masson, 1986). The male
professional's sense of identification with the male perpetrator (intensified because both
roles-health care professional and sex abuse perpetrator-involve being the more powerful
member of a private dyad) may, according to this view, elicit the professional's collusion
in exonerating the perpetrator's accountability for his acts and/or enabling the perpetrator
to continue the abuse (e.g,, through unsubstantiated claims of "rehabilitation"). Thus the
professional is placing an aspect of (perceived) self-interest (based on identification with
the perpetrator) above the interests or needs of the victim.
Health care professions, like any professions, struggle constantly with the conflict
between "self-interests" (often termed "guild interests") and the ethic that professionals
will scrupulously act in ways that safeguard the safety of patients. In an analysis of issues
related to the withholding of care from people suffering from AIDS, Pellegrino (1987), of
the Kennedy Institute of Ethics, wrote
Nothing more exposes a physician's true ethics than the way he or she balances his or her
own interests against those of the patient. Whether the physician is refusing care for
patients with the acquired immunodeficiency syndrome (AIDS) for fear of contagion ...
or withdrawing from emergency department service for fear of malpractice suits, striking
for better pay or fees, or earning a gatekeeper's bonus by blocking access to medical care,
the question raised is the same. (p. 1939)
Pellegrino argued that it is various aspects of a commitment to forgo certain self-interests
in order to protect or serve the welfare of patients "that distinguish medicine from
business and most other careers or forms of livelihood" (p. 1939). Medicine's
commitment to such a professional ethic may be in the process of erosion. The president
of the Association of American Medical Colleges, for example, noted that "studies show
that medical students are lenient towards dishonesty in education and practice"
(Petersdorf, 1989, p. 119). Students' lenient attitudes toward fraudulent practices that
benefit the professional at the expense of the patient may be influenced by the less-thanvigorous systems of discipline and accountability in which physicians play an active role.
An extensive study, for example, concluded, "Physician discipline in California is a code
blue emergency. The system cannot and does not protect Californians from incompetent
medical practice" (Center for Public Interest Law, 1989, p. 1). For further examples and
discussion of professional review boards, see Sonne and Pope (in press) .
The resistance to accountability and resultant erosion of effective monitoring of
compliance with professional standards may be operative in the area of therapist-patient
sexual intimacies. The American Psychiatric Association, for example, has been
criticized by some members for its failure to address this issue in good faith. Gartrell, a
former professor at Harvard who was principal investigator in the first national study of
sexual intimacies between psychiatrists and their patients (Gartrell, Herman, Olarte,
Feldstein, & Localio, 1986, 1987 , 1989), resigned her membership in the American
Psychiatric Association in protest of what she considered their failure to act effectively to
maintain the prohibition, to protect patients, and to hold perpetrators accountable
(personal communication, November 14, 1989). Similarly, Gay, a member of the
American Psychiatric Association who has been deeply involved in efforts to hold
therapists accountable for sexual abuse of their patients concluded, "I used to believe the
[American Psychiatric Association]... . But they want to have one image publicly, then
the way they act supports a completely different conclusion. I think the [American
Psychiatric Association] is not part of the solution; I think the [American Psychiatric
Association] is part of the problem" (Terwilliger, 1989c, p. F2). A former president of the
American Psychiatric Association suggests that economic interests may heavily influence
responses to accountability for victimization. Observing that liability insurance has
traditionally served the dual purpose of protecting practitioners economically and
compensating patients victimized by malpractice, A. A. Stone (1990) maintained that it is
hard to justify the policy limits on payment to the (mostly female) victims of sexual
exploitation by therapists. He noted that the economic selfinterest of these limits is "often
presented with the windowdressing argument" (p. 25) that the perpetrators should not be
protected. This conflict of interest, according to A. A. Stone, seems to lead to the placing
of greater weight on economic self-interest (i.e., keeping malpractice premiums used to
cover the costs of damages from becoming too expensive for therapists) than on the
profession's concern for victims. "The point is that the American Psychiatric Association
will continue to have an economic interest in defending victimizing doctors who have
committed the most egregious sexual exploitation if only to limit the amount of damages
awarded" (p. 26). If psychologists are to create an effective method for eliminating the
sexual abuse of patients, the possible tension between individual and collective selfinterest and the safety of patients must be confronted forthrightly.
However, there is a second, related factor that may make it even more difficult to institute
effective mechanisms of accountability. Many of us may be exceptionally wary of any
efforts to monitor or regulate our actions, even (or especially) if such efforts are made by
our own professional association. The history of the APA is interesting in this regard. The
APA held its first meeting in 1892, ratified its constitution in 1894, and became
incorporated in 1925. Yet it was not until the late 1930s that it was able to create an
ethics committee in an attempt to ensure high standards among its membership. Prior
attempts to regulate the practice of professional psychology included three separate
efforts in the 1920s to establish a system of certifying psychologists performing clinical
services (Fernberger, 1932). The third attempt ended when fewer than 30 psychologists
could be persuaded to apply for certification-even when the application fee was
drastically reduced from $35 to $5. The Committee on Certifications issued a report
suggesting that by virtue of the scientific framework of the profession, psychologists,
"while commonly energetic and at times heroic in the pursuit of personal aims and ideals,
seldom exhibit the capacity for resolute common action which [would be necessary to
maintain adequate standards despite] the energy and resources which would be mustered
by [colleagues] charged with misconduct" (Fernberger, 1932, p. 50).
Accusations and Guilt; Denials and Innocence
A third pitfall can be anticipated from a study of responses to other forms of sex abuse:
the danger of judging accusations or denials of therapist-patient sex to be always true or
always false. Each accusation and denial must be painstakingly evaluated on an
individual basis. This principle would seem so obviously self-evident as to be at best an
innocuous truism. Yet the history of professional reactions to sexual abuse indicate how
easily this principle is violated.
Perhaps influenced by Freud's recantation of his seduction theory, many professionals
and courts alike seemed to accept the premise that children's allegations of incest or other
forms of sexual abuse by adults were virtually always invalid (Masson, 1984; Miller,
1984 ; Rush, 1980). Other professionals, however, maintained that "young children never
make up specific sexual stories or lie about who molested them" (Siegel, 1989, p. 29).
The phenomenon of sexual intimacies between therapists and patients may provoke
similar tendencies to prejudge, especially in light of the issues involved and the tendency
of sex abuse accusations to elicit intense emotional reactions. All of us must become
aware of the ways in which our careful, unbiased evaluation of individual accusations and
denials may be distorted by strong desires to protect innocent colleagues (and perhaps
also those who engage in sexual abuse) from accusations, from involvement in formal
hearings, and from sanctions, and to protect patients not only from victimization but also
from revictimization that comes from having valid complaints discounted. Psychologists
serving as expert witnesses in court settings or as members of ethics committees,
licensing boards, hospital peer review committees, or other deliberative bodies have an
especially significant responsibility to ensure that they render a thoroughly honest, truly
professional judgment. Great harm is done to a practitioner innocent of any sexual
involvement with a patient when a false accusation is, through carelessness, bias, or other
factors, formally judged to be true. Great harm is done to both current and future victims
of an actual perpetrator when a victim's accusations are unfairly dismissed, discounted, or
minimized. Psychologists must be particularly careful when using standardized tests to
evaluate alleged perpetrators or alleged victims to ensure that the test has been adequately
normed and validated for the relevant population and for the use to which it is being put,
especially in light of evidence that failure to do so when using such tests as the Minnesota
Multiphasic Personality Inventory (MMPI) can result in serious errors (Butcher & Pope,
1990; Pope & Bouhoutsos, 1986; Pope, Butcher, & Seelen, 2000).
The Nature of Information, Evidence, and Knowledge
A fourth challenge to psychology and allied health professions is in confronting the
question, What forms of information or research evidence regarding sexual intimacies
between therapists and patients will be considered persuasive (Pope, 1986)?
What we will accept as evidence regarding such intimacies depends in part on our
epistemological assumptions. Numerous writers have explored the nature, validity, and
implications of diverse scientific methods, with considerable attention to the social and
behavioral sciences (e.g., Adair, 1973; Ash & Woodward, 1988; Bannister, 1987; Barber,
1976; Child, 1973; Cook & Campbell, 1979; Flanagan, 1988; Hilgard, 1987; Kuhn,
1962/1970, 1977; Manicas, 1987; Piaget, 1970/1977; Plutchik, 1968; Polanyi, 1958;
Popper, 1935/1959; Rosaldo, 1989; Rosenthal & Rosnow, 1975; Rychlak, 1977; Sarason,
1988; Staats, 1981; Ziman, 1968). In his survey, Kimble (1984) found a diversity of
views within the field of psychology. An extreme view holds that the only acceptable
psychological method is that employed by a few (not all) of the natural sciences: Only
when quantifiable variables can be isolated, randomly assigned, and manipulated in a
controlled environment is the evidence acceptable. According to this view, paleontology,
anthropology, ethology, and astronomy are not genuine sciences in that they rest
primarily on careful and systematic observation of naturally occurring phenomena that do
not permit substantial experimentation with completely isolated and randomly assigned
variables in a controlled environment. This appears to be a minority view. M. Levine
(1974) noted and endorsed the shift from the stance "that all problems are better handled
with the logic of experimental design and statistical inference" to a general recognition
that the real dilemma for psychology was to "distinguish between problems that can be
studied by experimentation and those that cannot" (p. 664). A decade later, Wittig's
(1985) review of the field led her to conclude,
Most researchers in psychology recognize that exclusive reliance on the methods of the
natural sciences does not provide a proper basis for psychology. The challenge is to gain
consensus concerning the strength of the conclusion to be drawn, given the power of the
techniques employed. (p. 805)
Whatever the customary epistemological stance may be, any association that finds itself
accused of causing harm to the public (e.g., that members of mental health professions
are sexually abusing their patients, are not acting vigorously and effectively to prevent
this abuse, and are enabling perpetrators to resume practice with vulnerable patients on
the basis of unvalidated claims of rehabilitation) may tend to defend itself by pointing out
that any evidence of harm does not meet sufficiently rigorous scientific standards. The
tobacco industry, for example, correctly points out that the evidence supporting the
hypothesis that smoking harms or at least endangers humans does not meet certain
scientific criteria (see, e.g., Patterson, 1987): (a) the animal studies-in which isolated
variables are randomly assigned in a controlled environment (e.g., precise control of
exactly how much smoke is inhaled over specified temporal intervals, of all facets of diet
that might interact with smoking effects, of all environmental variables, of relevant
genetic predispositions)-cannot be assumed to have direct implications for another
species (i.e., humans), and (b) none of the human studies involve random assignment to
smoking and nonsmoking groups or adequate isolation of variables; for example, all
smokers are self-selected (thus introducing a bias of indeterminable magnitude), and
those smokers who do volunteer for studies may differ in significant ways from those
smokers who decline to participate.
Interestingly, when APA acquired Psychology Today, a venture hailed as "a far-sighted
and sagacious move in the direction of social responsiveness [and] primary prevention"
(Salameh, 1984, p. 4), it became the only health profession to generate considerable
revenue by running advertisements that urged consumers to use tobacco products,
although certain other types of advertisement were unacceptable. The APA Board of
Directors unanimously agreed to issue a public policy statement in which the association
did not characterize smoking as harmful (see, for example, the Surgeon General's
Warning on cigarette packets that "Smoking causes lung cancer, heart disease,
emphysema, and may complicate pregnancy") but rather adopted more scientifically
conservative language, concordant with the tobacco industry's position, to assert that
cigarettes are one of a number of "products considered by some to be hazardous"
(Advertising policy adopted for magazine, " 1983, p. 2). It is crucial that we maintain an
active awareness of the degree to which individual or collective defensiveness may be
biasing our evaluations of whether certain actions actually cause harm.
The issue of what constitutes acceptable evidence is accentuated in the area of sexual
abuse. As the professions began to overcome their resistance to acknowledging such
phenomena, some professional authorities assumed that the activities labeled sexual
abuse tended to be neither more nor less harmful than other forms of human sexual
interactions. Kinsey, Pomeroy, Martin, and Gabbard (1953), for example, in their
landmark text, Sexual Behavior in the Human Female, did not follow up on the fact that
80% of the girls who had engaged in sexual intimacies with adults reported that they
were "emotionally upset and frightened." The researchers viewed such relationships as
essentially no different from those sexual relationships between adults in which one
person has not assumed responsibilities relating to the welfare of the other, could not be
considered to be more powerful than the other, and so forth. Any human sexual
relationships, according to Kinsey and his colleagues, might produce a little upset; incest
was not inherently different. Any general harm could be reasonably attributed only to
outmoded cultural or professional biases against such relationships:
It is difficult to understand why a child, except for its cultural conditioning, should be
disturbed at having its genitalia touched, or disturbed at seeing the genitalia of other
persons, or disturbed at even more specific sex contacts.... Some of the more experienced
students of juvenile problems have come to believe that the emotional reactions of
parents, police officers, and other adults who discover that the child has had such a
contact, may disturb the child more seriously than the sexual contacts themselves. (p.
121)
Those who assert that incest is no more generally harmful than sexual liaisons between
adults in which one person has not assumed responsibilities relating to the welfare of the
other, could not be considered to be in a more powerful position than the other, and so
forth argue that fatally flawed research is being misinterpreted by people imbued with
outmoded cultural prejudices. They compare incestuous activity to a private, selfinitiated, and completely solitary sexual activity (which thus precludes consideration of
issues of power or trust with a second party, fiduciary concerns, etc.). Herman (1981)
noted the tendency of what she termed the "pro-incest school of thought" to use this
comparison to masturbation. As Ramey (1979), a widely quoted sociologist, wrote, "We
are roughly in the same position today regarding incest as we were a hundred years ago
with respect to our fear of masturbation" (p. 1). Henderson (1983) likewise decried what
he viewed as the unjustified prejudice against both masturbation and sexual intimacies
between adults and children within a family, and quoted approvingly D. P. Orr's
dismissal of any evidence to date: "The studies used to support allegations that sexual
abuse of children is damaging are biased and selected for children already identified as
disturbed" (p. 38).
Some professionals, though rejecting any evidence of possible harm, may accept
evidence of possible benefits. For example, in the chapter on "Incest" in the
Comprehensive Textbook of Psychiatry, Henderson (1975) called attention to such
methodological problems in the research as "unfortunate sampling procedures in the
study designs" and, though unable to find adequate evidence of general harm, was able to
conclude,
The father-daughter liaison satisfies instinctual drives in a setting where mutual alliance
with an omnipotent adult condones the transgression. Moreover, the act offers an
opportunity to test in reality an infantile fantasy whose consequences are found to be
gratifying and pleasurable. It has even been suggested that the ego's capacity for
sublimation is favored by the pleasure afforded by incest and that such incestuous activity
diminishes the subject's chance of psychosis and allows a better adjustment to the
external world. There is often found to be little deleterious influence on the subsequent
personality of the incestuous daughter. One study found the vast majority to be none the
worse for the experience.... (p. 1537)
Likewise, Karl Menninger, addressing the issue of sexual activity between children and
adults, once noted that "when the experience actually stimulates the child erotically, it
would appear ... that it may favor rather than inhibit the development of social
capabilities and mental health in the so-called victims" (cited by Dziech & Schudson,
1989, p. 8). Similarly, D. Thiessen's paper, "Rape as a Reproductive Strategy, " at the
annual meeting of the APA in 1983, prompted consideration of whether rape might have
certain benefits for women as a reproductive strategy. He asserted that "patterns of rape
seem to follow normal correlates of consenting adults" and that such commonalities
suggest that rape may possess "sexual and reproductive facets geared toward the
reproductive facility of women" (quoted by Cunningham, 1983, p. 22).
In the area of sexual intimacies between therapists and persons with whom they have
developed a professional, fiduciary relationship, it is crucial to confront realistically the
nature of the research. For example, researchers have examined the effects of abuse on
patients who did not return to a subsequent therapy as well as on those who did, have
compared patients who were subjected to abuse by a prior therapist with matched groups
of patients who were not victimized, and have explored the sequelae as evaluated
variously by the patients themselves, by subsequent therapists, and by independent
clinicians through methods including observation, clinical interviews, and standardized
psychological testing (Belote, 1974; Bouhoutsos, Holroyd, Lerman, Forer, & Greenberg,
1983; Brown, 1988; Butler, 1975; Chesler, 1972; Durre, 1980; Feldman-Summers, 1989;
Feldman-Summers & Jones, 1984; Sonne, 1989; Sonne, Meyer, Borys & Marshall, 1985;
L. G. Stone, 1980; Vinson, 1984). Yet some might still argue that because it is impossible
to assign subjects randomly, to isolate and control all variables, and so forth, researchers
cannot determine whether therapist-patient sex, rape, incest, or other forms of abuse are
generally harmful or are actually more likely to be enjoyable and beneficial to the
(predominantly female) individuals who experience them and that attempts to answer
such questions must rest solely on transient cultural prejudices rather than on acceptable
scientific evidence. Riskin (1979) maintained that researchers will find out whether
sexual intimacies with patients are generally harmful or beneficial only if they conduct
experiments on patients in which therapist-patient sexual activity is the independent
variable; he recommended that patients be randomly assigned to sexual and nonsexual
treatment conditions.
If we do not reject all evidence concerning sexual abuse as failing to meet scientific
criteria, we must take seriously the limitations and qualifications emphasized by reports
of the research. For example, Holroyd and Brodsky (1977) stressed that it is "crucial to
consider reliability issues" (p. 848); Bouhoutsos et al. (1983) emphasized that "the
meaningfulness of these data ... must be evaluated in the light of our sample
characteristics... . We do not know the effects for patients who did not return to therapy"
(p. 192); and Borys and Pope (1989) underscored six validity issues, one of which
concerns a cluster of issues involved in their approach to data interpretation, including
problems in sample selection, the potential similarities and differences between
responders and nonresponders in survey studies, issues in scaling and statistical analysis,
[and] the qualified nature of inferences drawn from specific findings. (p. 289)
It is only when such qualifications regarding validity and reliability are carefully taken
into account that what Wittig (1985) termed the "power of the techniques" can truly
emerge and the difficult, often frustrating struggle to learn from diverse investigations-each adding a piece of the puzzle--can proceed.
The Nature of Perpetrators and the Questionable Nature and
Efficacy of Rehabilitation
A prevalent societal and professional misconception about rapists and incest perpetrators
has been (at least generally) laid to rest: that they are predominantly the least educated,
least respected, most marginal members of the community (Barnard, Fuller, Robbins, &
Shaw, 1989; Estrich, 1987). Lanyon (1986), for example, noted in his review of the
literature that
Most prominent is the stereotype that child molesters are socially marginal persons or
"dirty old men." Indeed, the child molester is most commonly a respectable, otherwise
law-abiding person, who may escape detection for exactly that reason. (p. 177)
Similarly, there emerged a stereotype (and, regrettably, it may have been cultivated by an
embarrassed profession): that therapists who sexually abused patients were those
marginal members of the profession who were most poorly trained. Such stereotypes
served as the basis for numerous optimistic rehabilitation efforts that generally involved
some combination of (a) education (e.g., an ethics tutorial, continuing case consultation
or supervision, and individualized courses in issues such as countertransference,
boundary management, and sexual material in psychotherapy), and (b) intensive, longterm psychotherapy lasting several years. Unfortunately, neither education nor
psychotherapy has shown any evidence in published research studies of inhibiting sexual
abuse of patients, and according to some studies, they actually appear to be positively
associated with tendencies to abuse (Pope, 1990). For example, a national study of
psychiatrists revealed that "offenders were more likely [than nonoffenders] ... to have
completed an accredited residency ..., and to have undergone personal psychotherapy or
psychoanalysis" (Gartrell et al., 1989, p. 7). Similarly, a national study of social workers
revealed that personal therapy was not associated with lower rates of sexually abusing
patients and that perpetrators were more likely than nonperpetrators to have fulfilled
additional requirements for inclusion into the National Academy of Certified Social
Workers (Gechtman, 1989). A study of knowledgeable, well-trained, and successful
psychologists revealed a higher rate of sexual abuse of patients than that found in the
more general surveys of psychologists (Pope & Bajt, 1988). It is worth considering
whether high educational accomplishment and professional status may not only, in
accordance with Lanyon's (1986) speculation, help perpetrators to avoid detection but
also contribute more generally to some psychologists' sense that they and their colleagues
are (or should be) above the law and beyond accountability to which other less entitled
citizens are subject, that they are too elite and knowledgeable to be subject to such
restraints, and that even to call their behavior formally into question is an affront and may
be unethical. For example, in one study of exceptionally accomplished and respected
senior psychologists (Pope & Bajt, 1988), 9% of those who reported intentionally
breaking formal legal and ethical standards revealed that the standard they violated was
the prohibition against sex with a patient and that this violation was an act of professional
responsibility (i.e., that they engaged in sex with the client to promote "client welfare").
Another study of psychologists (Pope, Tabachnick, & Keith-Spiegel, 1987) revealed that
2.4% believed that to formally report a colleague's harmful behavior under any
circumstances was inherently unethical behavior on the part of the psychologist filing the
complaint; an additional 12.8% believed that reporting such behavior was ethical only
under rare circumstances.
Civil disobedience (a term coined by Thoreau, 1949/1960) was developed as a concept of
ensuring accountability through voluntary acceptance of the penalties for breaking laws
considered to be unjust and oppressive as a means of bringing about social change
(Gandhi, 1948; King, 1986; Plato, 1956a, 1956b; Thoreau, 1849/1960; Tolstoi,
1894/1951). For psychologists to arrogate this term to avoid accountability for engaging
in sexual abuse, keeping secret the sexual abuse of others, committing perjury, faking
professional credentials and obtaining expensive gifts from clients seems, at best,
misguided (see Pope & Bajt, 1988).
Sexually abusive psychotherapists cannot be dismissed as the most marginal members of
the profession. They are well represented among the most prominent and respected
mental health professionals. Cases involving therapists publicly reported to have engaged
in sexual behaviors with their patients have included those who have served as faculty at
the most prestigious universities (including those with APA-approved training programs),
psychology licensing board chair, state psychological association ethics committee chair,
psychoanalytic training institute director, state psychiatric association president, state
association of marriage and family therapists president, prominent media psychologist,
chief psychiatrist at a prominent psychiatric hospital, and chief psychiatrist at a state
correctional facility ("APA's Ethics Procedures Upheld," 1985; Bass, 1989; Bloom, 1989;
Colorado State Board of Examiners, 1988; Jalon, 1985; Matheson, 1984, 1985; Pugh,
1988; "The Resignation of ___ ___," 1990; Smith, 1984). Bates and Brodsky (1989)
described how one psychologist gained publicity by reporting a "nationwide survey"
based on the conceptualization that sexually abusive therapists were in fact "impaired
professionals", the survey findings, which received newspaper coverage, supported
efforts to "rehabilitate" these professionals. The psychologist also made a presentation on
the subject of rehabilitating perpetrators at an annual meeting of the APA. The general
public and the professional community, however, were probably not aware that this
psychologist had been engaging in therapist-patient sexual intimacies and, several years
after the APA presentation, pleaded guilty to a sex abuse charge (see Bates & Brodsky,
1989).
The ease of demonstrating the apparent successfulness of a rehabilitation program--even
when the fundamental research requirement that data be collected and analyzed by
independent, disinterested researchers (insofar as any efforts that we undertake to
evaluate and publicize the appropriateness, successfulness, and downright brilliance of
our own clinical work are rarely disinterested) is met--is due in part to the low base rate
phenomenon. Cases of therapist-patient sex abuse have demonstrated that it is possible
for perpetrators to engage in sex with their patients undetected (at least until one of the
patients breaks the "secret" and files a complaint) while receiving close and direct case
supervision, even when the supervision is conducted by an experienced and skilled
psychologist under the mandate and auspices of a licensing board (in one instance
reported by Bates & Brodsky, 1989, a malpractice suit was filed against both the
perpetrator/therapist and the board-approved supervisor conducting the
rehabilitation/monitoring), while working within a prestigious agency, and while
maintaining a high public profile. Formal complaints from patients may be thus the only
reliable way in which the failure of a rehabilitation effort can be discovered. Surveys of
victims suggest that about 5% actually file formal complaints (e.g., Bouhoutsos, 1984;
Pope & Bouhoutsos, 1986); the percentage seems to be significantly less than 5% when
the number of cases estimated from anonymous surveys of therapists are compared with
the number of complaints reported by regulatory agencies, ethics committees, and the
civil courts.
What are the implications of these facts for rehabilitation? Assume that a hypothetical
Sex Abuse Rehabilitation Institute will be created to work with 10 offenders referred by
the state licensing board. After many years of intensive psychotherapy, education, and
supervision--which, as noted earlier, have not shown evidence of effectiveness in
preventing sexual abuse of patients--as well as careful use of other methods, the Institute
honestly believes that these 10 psychologists have been fully rehabilitated and are ready
to resume clinical practice, despite the relatively high tendency toward recidivism. [The
APA Insurance Trust (1990) noted that "the recidivism rate for sexual misconduct is
substantial (p. 3). The rate may be at least 80% (California Department of Consumer
Affairs, 1990; Holroyd & Brodsky, 1977; Pope, 1989b; Sonne & Pope, in press).]
Assume that the Institute's interventions are completely ineffective and that every one of
these 10 perpetrators will offend again (each with a new patient) once the licensing board
allows each to resume practice. Even if the Institute and licensing board track the
offenders for the next 20 years, what are the chances that they will discover that even one
of the 10 therapists continued to abuse? According to the binomial probabilities, there is a
59.9% likelihood that none of the 10 subsequently abused patients will ever file a
complaint. Thus the Institute and licensing board might in good faith publicize glowing
findings that all 10 were rehabilitated and that patients and the public were adequately
protected when in fact all 10 perpetrators continued to abuse.
At present, the diverse attempts to rehabilitate therapists who perpetrate sexual abuse
have not demonstrated success in replicated research studies (even with the misleading
"aid" of the low base rate phenomenon). Moreover, executive directors for the California
licensing boards for psychologists, social workers, and marriage and family counselors
have reviewed rehabilitation attempts. Having encountered more offenders than the
licensing boards of other states, the California boards have had opportunity to test the
widest variety of rehabilitation approaches. The executive directors concluded that in
cases involving therapists who became sexually intimate with a patient, "prospects for
rehabilitation are minimal and it is doubtful that they should be given the opportunity to
ever practice psychotherapy again" (Callanan & O'Connor, 1988, p. 11).
The dilemma of rehabilitation is not limited to the highly questionable feasibility or
demonstrated efficacy of rehabilitation. Among the other aspects of the dilemma are two
major questions. First, what level of inviolable integrity and trust, if any, does the
profession wish to affirm and sustain? A judge might take a bribe to decide a major case,
lose the judgeship, subsequently pay the debt to society through a prison term, and
undergo extensive rehabilitation; yet the judge would obviously not resume the bench. A
teacher running a preschool might sexually abuse the children, subsequently undergo
extensive treatment and rehabilitation and satisfy legal requirements (i.e., jail or
probation), and seem to present no threat of further abuse; yet the teacher would not
subsequently be granted a license to operate a preschool (unless, of course, the teacher
was able to conceal this history of child molesting, perhaps by moving to another state
and providing false answers during the application process). If people found to have used
their positions of trust to accept bribes for rendering certain legal decisions or to
victimize students were allowed to resume the positions of trust that they had betrayed,
the nature of those positions-what they mean to the society and to those whose lives they
influence-would be profoundly changed. Violation of a clearly understood prohibition
against such a grave abuse of power and trust precludes further opportunity to hold these
special positions in the legal or educational professions, although numerous other
opportunities in law or education (e.g., research, writing, and consultation) remain
available to the rehabilitated perpetrator.
Psychology must answer the question of whether psychotherapy involves, requires, and
deserves the same level of inviolable trust (both from society and from those who are
directly affected by the therapist) and integrity as judiciary and teaching roles within the
legal and educational professions. The exceptional privacy and intensity of most
psychotherapy relationships should not be overlooked when one confronts this question.
Second, to what degree does the profession affirm and ensure the rights to informed
consent of patients directly affected by rehabilitation efforts? When new, not-yetvalidated rehabilitation methods for perpetrators are being used on an experimental or
trial basis by independent clinicians and professional boards, are the patients who are
treated by the perpetrators during these initial investigative trials accorded full awareness
and written informed consent to their participation, as the Ethical Principles in the
Conduct of Research With Human Participants (APA, 1982) clearly seems to require? If
the rehabilitation methods have already been independently validated, are the patients
made aware of the nature of evidence supporting the validity of the approach and of any
doubts, reservations, or qualifications regarding the safety and potential fallibility of the
method? [Footnote1]
Our responsibility to scrutinize carefully the methods for ensuring informed consent used
by clinicians, researchers, licensing boards, ethics committees, and others involved in
rehabilitation efforts is vital: The patients placed at risk for serious harm are
predominantly female, and informed consent procedures may be less adequate or
completely nonexistent when risks for harm from experimental efforts fall mainly on
women and minorities (Gallagher, 1990; R. J. Levine, 1988).
Psychologists must overcome professional resistance to the collection and public
disclosure of such data (see the section on Acknowledging the Scope of the
Phenomenon). It may also be worth considering whether any victim of rape, sexual abuse
from a therapist or of incest who is considering seeking help from a therapist is genuinely
aware that the therapist she or he selects may have sexually abused patients and has been
returned to practice, after some sort of rehabilitation effort, by licensing boards.
A responsible professional stance is incompatible with neglect of these issues. All of us
must maintain an active and knowledgeable awareness of such factors as (a) the consent
forms and other components used by those (e.g., individual clinicians, professional
licensing and ethics boards) who develop, study, publicize, and use rehabilitation
attempts that have not yet been formally validated to ensure adequate informed consent
by patients placed at risk by the perpetrators, and (b) the measures used to assess the
reliability and validity of untested (i.e., having yet to show demonstrable effectiveness)
approaches to rehabilitation, with special attention to how the psychometric properties of
those measures and how the low base rate of discovery of abuse are taken into account.
Are Patients Responsible for Therapist -Patient Sexual Abuse?
If the history of other forms of sexual abuse such as incest and rape is a useful guide, it is
likely that psychology will need to confront more directly the issue of the degree to
which a patient will be viewed as responsible for intimacies with a therapist. The
prominent psychiatrist Lauretta Bender, for example, stressed the frequency with which
the child engaging in sex with an adult is "the actual seducer rather than the one
innocently seduced" (Bender & Blau, 1937, p. 514). Similarly, Henderson (1975)
concluded, "The daughters collude in the incestuous liaison and play an active and even
initiating role in establishing the pattern" (p. 1536). The focus on the victim as
responsible for sexual abuse is also a major theme concerning rape. Amir (1971), for
example, observed in his classic study of forcible rape, "Thus, the role played by the
victim and its contribution to the perpetration of the offense becomes one of the main
interests of the emerging discipline of victimology" (p. 258).
These professional views are reflected vividly in the legal system. In one case, the judge
refused to confine a person who had pleaded no contest to sexually assaulting a 16-yearold girl. The judge observed that rape is a "normal" reaction to the girl's "provocative
clothing" (i.e., blue jeans, a blouse over a turtleneck sweater, and tennis shoes): "Whether
you like it or not, a woman's a sex object and they're the ones who turn the man on,
generally" ( "A Woman's a Sex Object, " 1977, p. 2). Another judge refused to convict
two adults of raping an 8-year-old girl because she was, in the opinion of the judge, "a
willing participant" ( "Judge urged to resign, " 1985, p. A6). Still another judge took a 5year-old girl's "character" into account in discounting the responsibility of the 24-yearold man who sexually assaulted her; the judge observed that the girl was "an unusually
sexually promiscuous young lady. No way do I believe that [the adult] initiated the sexual
contact" ("Unbelievable, " 1983, p. F2). A recent study revealed that for jurors, evidence
concerning the victim's "moral character" tended to count more in rape cases than did
medical evidence or other evidence regarding the injury (Mansnerus, 1989, p. 20).
Psychology must struggle with the question of the degree to which it will endorse and
focus on the concept of patients as responsible (e.g., through their clothing, behavior,
clinical syndromes such as borderline or hysterical disorder, sexual histories or
tendencies, difficulty managing boundaries or limits, etc.) for therapist-patient sexual
intimacies. Wright (1985), for example, argued that there is no power imbalance in
therapeutic relationships: "The therapist is every bit as much in the power of the
consumer, as the consumer is in the power of the therapist. In that sense, the relationship
is no different from any other human interaction" (p. 117). He maintained that the
vulnerability of the therapist invites abuse by the patient; some "consumers recognize the
vulnerability of the provider and are attempting to exploit that vulnerability for economic
gain" (p. 114). But in Wright's analysis, which he noted was based on his extensive
experience chairing The APA Insurance Trust and on his professional work with both
victims and perpetrators, not all of the patient's motivations to engage in sex with a
therapist and to file a subsequent complaint are economic. Attempting to provide a more
complete answer to his fundamental questions of whether and why "they are unable to set
limits for themselves or the provider" (p. 116), Wright asserted "the very strong
probability that the real reason 'victim/patient' didn't set a limit for the provider [or file a
formal complaint] was the unwillingness of that same 'victim' to give up personal
gratification [the consumer enjoyed in the relationship]" (p. 116; bracketed text appears
in the original).
Similarly, Serban (1981) focused on the motives and characteristics of the patient; the
only suffering that can result from therapist-patient sex and the only reason why a patient
might "complain against the previous mutual agreement to engage in sexual interaction
that she negotiated with her therapist" is, according to Serban, that the results are "not
meeting her self imposed expectations" (p. 81). The female patient's expectations from
sex with the therapist are, according to this view, "finding either a sexual and emotional
partner or otherwise to make a handsome financial profit by defrauding the therapist's
insurance, if not to victimize him as revenge against men" (p. 81); complaints are thus
based on the patient's anger at the failure of the therapist, despite the patient's having
entered into a sexual relationship, to "satisfy her dreams of either marrying her or
compensating her financially" (p. 82).
Expert witnesses and defense attorneys have frequently maintained this focus on the
motives, acts, or characteristics of the patient. One attorney with substantial experience in
trying such cases (and who had similar experience defending people accused of rape)
stressed that in therapist-patient sex cases, the primary "defense includes trying to prove
that the victims are promiscuous, trying to prove the clients were asking for it"
(Terwilliger, 1989a, p. D1). Thus a detailed exploration of the patient's entire sexual
history, orientation, current and previous sexual partners (by name so that they can be
deposed by the defense attorney in order to obtain baseline data about the patient's
previous sexual relationships and sexual functioning), desires, fantasies, and
characteristics may become a focus of the trial and perhaps a matter of public record. A
patient described the questions that she was directed by the defense attorney to answer
under oath:
Could I mentally control vaginal lubrication? At what angle were my legs spread? Did I
have orgasms?... Have you ever had occasion to swap sexual partners with anybody?...
Have you ever had sex in front of anybody else?... And when you engaged in sex, did you
just have intercourse with these people or would you have oral sex with them, too? (
Bates & Brodsky, 1989, p. 66)
The attorney also asserted that in order to present the psychologist's case properly, he
would require "a photograph of [the patient] to circulate at local bars... in order to gather
information about [the patient's] social life" (Bates & Brodsky, 1989, pp. 105-106). One
prominent defense attorney publicly called attention to the patient's race, presumably as a
relevant factor in assessing the degree to which the patient should assume responsibility
for failing to set limits for herself or the provider: "She was, you know, free, white and
21" (Terwilliger, 1989b, p. F1).
It is interesting to contrast the detailed interest that legal and mental health professionals
have taken in eliciting information from patients who have been victimized or may be at
risk for victimization regarding their "promiscuity, " sexual history, "predisposing"
clinical conditions, difficulties setting limits, and so forth, with the less-than-vigorous
efforts to obtain such information from professionals who have engaged in sexual
intimacies with their patients. The chair of the Ethics Committee of the American
Psychiatric Association explained why the association did not support the national
anonymous survey of its members (i.e., Gartrell et al., 1986, 1987, 1989): The
organization does not believe in asking its members for "sensitive information about
themselves" (Bass, 1989, p. 28).
In struggling with the question of whether to place part or all of the responsibility for
therapist-patient sexual intimacies on the patient-an effort that some might term "blaming
the victim" (Ryan, 1971)-it would be useful to keep in mind the data that have been
accumulated to date. As Bates and Brodsky (1989) summarized, "The best single
predictor of exploitation in therapy is a therapist who has exploited another patient in the
past" (p. 141). It might also be useful to consider Israel's approach to the problem of rape,
which was reaching epidemic proportions in Tel Aviv. The Prime Minister's cabinet
(mostly male) spent considerable time discussing ways in which women were putting
themselves at risk (e.g., in venturing out alone, in staying out after dark). The cabinet
concluded that, in light of women's seeming contribution to the epidemic, a legally
enforced curfew for women in the city should be enacted. The Prime Minister, Golda
Meier, changed the focus of the deliberations by remarking, "Why not a curfew for the
men? They are the ones doing the raping" (Unger, 1979, p. 427).
Conclusion
Confronting the reality of the sexual abuse of patients, both before and after termination,
is proving to be a difficult and stressful task for psychology, as it is for all mental health
professions. Part of the problem may be our discomfort with even acknowledging sexual
attraction to our patients (Maruani, Pope, & de Verbizier, in press; Pope, Keith-Spiegel,
& Tabachnick, 1986). Part may be our difficulty confronting issues of abuse that
predominantly affects women and is predominantly perpetrated by men (Frieze, 1986;
Gilbert & Scher, 1989; L. E. A. Walker, 1979, 1989). Part may be our difficulty handling
sexual issues in our training programs and relationships with our students (Glaser &
Thorpe, 1986; Pope, 1989a; Pope, Levenson, & Schover, 1979; Robinson & Reid, 1985).
Part may be our failure to become aware of and learn from examinations of sex abuse by
others in relationships of trust, such as the clergy (Hulme, 1989 ; Rassieur, 1976), sex
therapists (Redlich, 1977; Schover, 1989), and nonprofessional hospital staff (Collins,
1989 ; Kirstein, 1978). Part may be our reaction to the fact that we want to preserve both
our private and the public image of the profession as one that helps vulnerable and
hurting people. We may find it all but impossible to acknowledge fully and to respond
adequately when it is (members of) our own profession abusing the vulnerable person. In
this sense, we may find ourselves in the position of an enabling member of an incestuous
family: We may act in ways that keep the "family secret" (sometimes termed the
professional "conspiracy of silence"; see Gallagher, 1990; Macklin, 1987), that obscure
the responsibilities of the abusive professional and of his or her colleagues (i.e., us), that
enable the perpetrator to continue the abuse (perhaps after an unvalidated rehabilitation
program), and that excuse, justify, distort, deny, or discount the reality of what is
happening.
Such reasons may help explain our failure-as individuals and as a profession-to address
this phenomenon fully and effectively, but they are not an adequate excuse. When our
profession ceases to tacitly condone, passively tolerate, or actively collude with the
sexual abuse of patients-when, for instance, those who perpetrate such abuse are not
allowed to continue or resume working with patients but will need to engage in some
other form of psychological practice (e.g., research, consultation, writing, policy,
administration)-the trust that both patients and the public are able to bestow on the
profession may be of a far more realistic character and may be more genuinely deserved.
Awareness of the dilemmas, challenges, and pitfalls characterizing responses to other
forms of sex abuse may encourage a more careful and informed response to the sexual
abuse of therapy patients and may play a key role in psychology's scientific, professional,
and ethical development.
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Footnote #1: Readers may wish to obtain and review the consent forms used by
individual clinicians, clinics, licensing boards, ethics committees, and others who are
developing, implementing, supervising, or authorizing either experimental or fully tested
rehabilitation approaches for offending therapists to ensure that the ethical and legal
rights of the (mostly female) patients who are affected are not violated. Civil suits-some
of which lead to large verdicts for plaintiffs-against offending therapists seemed to play
an important role in bringing widespread attention to the importance of protecting
patients from abuse (Pope & Bouhoutsos, 1986); it would be regrettable if civil suits
against those involved in implementing rehabilitation programs were similarly necessary
to highlight the necessity of ensuring that fully informed consent has been obtained from
patients treated by the offending therapists in various stages of rehabilitation.