Bad Men Do What Good Men Dream: A Forensic Psychiatrist Illuminates the Darker Side of Human Behavior (29 page)

Female vulnerability and sexual coercion are woven into the fabric of our society. Efforts to understand sexual exploitation solely by means of individual psychological analysis of the particular victim or perpetrator often may overlook important societal-cultural factors. Such an analysis fails to recognize that sexual coercion is embedded throughout the structure and processes of most human culture. It would be a naïve error to conclude, however, that female professionals do not sexually exploit persons who seek their help. Nevertheless, female exploiters among professionals are in a distinct minority. Why male professionals are the perpetrators in the majority of the sexual exploitation cases is an extremely complex question. The answer involves cultural factors; for instance, men are acculturated to test boundaries, whereas women have been taught to accept boundary testing. There are also biological factors, for instance, the role of testosterone in producing sexual aggression. The evolutionary fact that men were hunter-predators may make some contribution to the male psyche. But cultural factors alone do not provide a satisfactory answer—the fact is that most male professionals do
not
sexually exploit their clients. This means that individual psychological factors play key roles for male professionals who
do
cross the boundary between maintaining their fiduciary role and sexual intimacy.

Therapist-Patient Sex

No accurate figures are available concerning the actual percentages of mental health professionals who commit acts of sexual misconduct. Most of the surveys that have attempted to ascertain the incidence of therapist-patient sex fall short on two counts: 1) the acts committed may be too narrowly defined, and 2) the survey methods are notoriously unreliable. Only about 15% to 25% of the therapists surveyed bother to respond. Also, the truth of what they have said on the survey cannot be verified independently. It can safely be assumed that most of the offenders do not respond to the survey, so that the real incidence must be higher than the reported incidence. That said, it must be pointed out that the reported figures are high enough to be of concern. A nationwide survey of 1,442 psychiatrists revealed 7.1% of male and 3.1% of female respondents acknowledged sexual contact with their own patients. Eighty-eight percent of these sexual contacts occurred between male psychiatrists and female patients, 7.6% between male psychiatrists and male patients, 3.5% between female psychiatrists and male patients, and 1.4% between female psychiatrists and female patients.

There has also been therapist sexual contact with child patients. In one study of 958 patients who were sexually exploited, 5% were minors. In another study exclusively of minors, the average age of sexually exploited children was 12 for male patients and 14 for female patients. Generally, psychiatrists, psychologists, and social workers have equal rates of sexual involvement with their patients.

Let me say it plainly: sex between a therapist and a patient
always
is unprofessional, is unethical, and constitutes malpractice. Psychiatrists, as physicians, pledge to first do no harm to their patients when they take the Hippocratic oath. Sex with a patient is
never
an acceptable form of treatment. Patients who come for psychiatric or psychological treatment are experiencing mental and emotional suffering that is painful and can be debilitating. Their decision-making capacities and judgment are usually impaired to some degree. Although the patient may not be incompetent to make major life decisions, he or she may have vulnerabilities and psychological blind spots that can be exploited. Moreover, the patient seeks out the therapist as a critically important source of help and hope. Under such circumstances, the patient frequently comes to idealize the therapist as the all-good, allpowerful parent figure. The patient, who is experiencing mental pain, is highly influenced by early, powerful yearnings to be comforted or cared for by the loving parent. Barbara Noël described her feelings for Dr. Jules Masserman by characterizing him as “my ‘healthy’ father figure.” Along with idealization of the therapist as a good parent comes the patient’s fear of losing this newly important figure in his or her life—a fear that increases the patient’s vulnerability to exploitation by the therapist.

Transference
is narrowly defined as the primary unconscious tendency of
all
individuals to assign to others in the present those feelings and attitudes that were originally connected to important figures in the course of their early childhood development. A more expansive, totalistic definition of transference includes the entire conscious and unconscious responses of the patient to the therapist. Transference occurs to some degree in all relationships but is particularly strong in fiduciarytype relationships. Mismanagement by the therapist of the patient’s powerful feelings from the past and the present is a key factor in the treatment boundary violations that lead down the slippery slope to sexual intimacy with the patient.

Therapists’ and Patients’ Thoughts of Each Other

The differential of power and authority that exists in professionalpatient relationships intensifies transference. In psychotherapy, the patient usually identifies the therapist with his or her parents or other important early figures. Carolyn Bates, in the book
Sex in the Therapy Hour
, which she cowrote with psychologist Annette M. Brodsky, described the growth of her feelings toward her therapist:

Over the months, in my weekly 45 to 50 minute sessions, I have no doubt that much of the trust and love I had for my father was directed toward Dr. X, for I perceived him as having both wisdom and an unconditional concern for my well-being.

Unfortunately, Ms. Bates later found that her intense feelings toward Dr. X were exploited by him. That is not the usual case. Transference feelings can be an important part of the patient’s treatment. On one end of the spectrum, some patients may resist or deny transference feelings; on the other end, some patients may wish to live out transference feelings with the therapist.

Therapists sometimes egregiously mismanage transference feelings when they accept at face value the patient’s expressions of love, adoration, and dependency. The well-trained therapist knows that, as with dreams, transference expressions are a surface presentation that hides a patient’s darker passions and attitudes. Feelings of love for the therapist may mask deeper feelings of hostility and anger that the patient must work out in the therapy. The psychodynamic, “insight” psychotherapist is trained to know how to manage the transference therapeutically and knows better than to exploit it for his or her own benefit. But insight psychotherapy is only one form of therapy. Although important, its use by itself has been declining in recent years. Today, the number of psychotherapeutic approaches, or “schools,” is above 450 and climbing. In all therapies, however, transference plays a role, either directly or indirectly, which means that all therapists, no matter what method of treatment they use, must be aware of the importance of transference in their work with patients.

Therapists must also be sensitive to their primarily unconscious emotional responses to the patient—
countertransference
—which can also present a danger to patients. In a strict sense, this is the therapist’s transference to the patient; that is, the therapist reexperiences feelings, thoughts, and behaviors toward the patient that have their origin in the therapist’s past relationships. More generally, the term countertransference refers to the totality of the therapist’s conscious and unconscious thoughts, feelings, and behaviors toward the patient. For example, the therapist’s countertransference to the patient may contain compelling erotic, incestuous feelings from early childhood that may be currently fueling a sexual interest toward a prohibited person—the patient. As with transference, countertransference exists in all relationships but is a particular problem in professional interactions. It can fuel the therapist’s temptation to exploit a position of power and commit sexual misconduct. As former secretary of state Henry Kissinger once observed, “Power is the great aphrodisiac.”

The inevitable countertransference feelings induced in the therapist regarding the patient can become a therapeutic window into the conflicts of the patient and into his or her characteristic ways of interacting with others. Insights gained through examining countertransference can assist the patient’s recovery. But countertransference feelings, particularly of the erotic variety, can also be occasion for the therapist mismanaging the patient’s treatment. Therapists get into trouble with patients when they are unable to hold, contain, and analyze their own feelings toward the patient. This is what the medical board in Massachusetts alleged had happened with Dr. Bean-Bayog, as they pinpointed her failure “to terminate or otherwise address” her sexual fantasies evoked in the treatment of Paul Lozano. The board found that her inability to deal with these issues was unacceptable.

Sexual exploitation of patients does not necessarily arise from transference or countertransference. Some therapists are—plain and simple—predators who pounce on vulnerable individuals. These therapists usually have severe malformations in their character and personality. In general, therapists who undertake long-term psychotherapy with patients should undergo their own psychotherapy or analysis, although this is not an absolute prerequisite. But the therapist must have or develop the ability to turn his or her mind on itself for the purpose of understanding personal problems, particularly in relation to the treatment of other people. For example, the lure for the therapist of having illicit sex with patients often has its roots in the therapist’s early incestuous desires. Understood and controlled, these feelings can prove useful in alerting the therapist to the nature of the material coming from the patient that may be stimulating incestuous feelings in the therapist. Misunderstood and uncontrolled, the feelings may lead to therapist-patient sexual misconduct.

With psychotherapists especially, the notion that bad men do what good men dream is of the essence. This notion is confirmed by a study showing that whereas 95% of the male psychotherapists and 76% of the female psychotherapists among 575 surveyed felt sexually attracted to their clients, only 9.4% of the men and 2.5% of the women acted on such feelings. Other studies show that nearly 75% of therapists have had sexual fantasies about a patient and 58% have become sexually aroused during therapy. Slightly more than 25% have had fantasies about a patient during sex with someone else.

When the Therapist Is a Woman

A significantly lower incidence of sexual misconduct by female therapists is a consistent finding of many surveys. Among those female therapists who do become sexually involved with their patients, the most common form of involvement is heterosexual relationships. Some female therapists, however, do develop what have been described as “tea and sympathy” relationships with female patients. These therapists are usually heterosexual and become overinvolved with the patient and overidentify with the patient’s problems. Their offers of tenderness and closeness may turn into hand-holding, kissing, fondling or even suckling the patient.

Numerous reasons (though not necessarily accurate ones) have been proffered to explain the lower incidence of sexual misconduct by female therapists:

• A strong mother-son incest taboo is unconsciously operating in the therapy, for both parties.
• Female therapists tend to have practices in which a higher proportion of their patients are women and children.
• The effects of maternal-child feelings generated by the treatment are sexually inhibiting for both parties.
• Women have been acculturated into nonpredatory roles; there is no female equivalent of the “macho” man’s role.
• Gender differences in the biological bases of aggression (e.g., the presence of more testosterone in males) affect incidence of sexual misconduct.
• The female therapist’s response to desperate, needy patients of the opposite sex is less likely to be erotically tinged than is the male therapist’s response because of acculturation and gender differences.
• Female therapists who are older are less likely to view themselves, and to be viewed, as sexual beings within the treatment context.
• Females, as a group, are more compassionate, nurturing, sensitive, and empowering of others.

Treatment Boundaries and the Slippery Slope

All professions establish professional and ethical guidelines for the conduct of their practitioners. For example, the Hippocratic oath taken by all physicians states
primum non nocere
—first, do no harm. The purpose of such guidelines is not only to protect the consumer from exploitation but also to provide good care. That is certainly true in the mental health field. All psychiatric therapies, regardless of their philosophical or theoretical orientation, are based on the fundamental premise that the therapist’s positive interaction with the patient is aimed toward alleviating psychic distress, positively changing the patient’s behavior and, in a meaningful way, altering the patient’s perspective on the world. In short, the therapeutic equation is a unique opportunity for a patient to obtain much-needed help. Exploitation of patients by therapists destroys this potential.

There are basic guidelines for the maintenance of treatment boundaries that are commonly accepted by most therapists. The concept of treatment boundaries, in fact, began in the twentieth century, largely as an outgrowth of psychoanalysis and psychodynamic psychotherapy. As early as 1909, the founder of psychoanalysis, Sigmund Freud, strongly disapproved of his disciple Sandor Ferenczi’s sexual involvement with his patient “Frau G” and her daughter “Elma.” Treatment boundaries were further defined by the ethical principles developed by the mental health professions and by the legal duties imposed on therapists by courts, by statutes, and by regulatory agencies. As a case in point, the therapist’s duty to maintain the patient’s confidentiality derives from three distinct sources: good professional care, ethical codes, and legislative mandates. Treatment boundaries are set by the therapist and not by the patient. It is the therapist’s professional duty to establish and maintain boundaries that define and secure the therapist’s professional relationship with the patient. Sound boundaries promote a trusting working relationship between therapist and patient.