Papers

Sexual Abuse in the Therapeutic Setting: What Do Victims Really Want?

Janet W. Wohlberg

Current research and reflection are bringing a new understanding of the meaning and impact of patient-therapist sexual relations. To some degree, this comes from recognizing the similarities this phenomenon bears to childhood sexual abuse and rape. All are life- changing, traumatic, and damaging events that occur in significantly power-imbalanced relationships. As with childhood sexual abuse and rape, there is finally recognition that it is neither productive nor appropriate to blame the victim. However, we have not yet succeeded in establishing a culture in which victims are freed from self-blame and allowed to believe that patient-therapist sex is always the responsibility of the therapist.

I have been asked by the organizers of this symposium to address four specific questions: What factors in the backgrounds and/or current lives of patients make them susceptible to becoming sexually involved with therapists?; What are some of the patient feelings or “danger signals” of patient-therapist behaviors that are discernible on the way towards sexual involvement?; What are some of the patterns of relationship that get played out in the course of a patient-therapist sexual liaison? and; What is the aftermath of such liaisons for the patient, and how does it affect subsequent therapy? To these, I have added my own question: What do victims really want?

As a victim of sexual abuse by a psychotherapist, and as one who has, over the past six years, come into contact with more than 800 other victims, I present in this paper a victim’s perspective of the answers to these questions about what happens, why it happens, and what we in the victim community believe the professional and lay communities can do, on both the micro and macro levels, to continue to change the existing culture. Because I am not a therapist, this paper is descriptive rather than interpretive.

An analysis of the phenomenon of patient-therapist sex must ultimately focus on issues of process, impact, and healing, rather than on an examination of patient pathology or behavior. Although questions about identifiable and shared characteristics of those most likely to become victims seem to be of understandable concern to those struggling to comprehend the phenomenon, it is important to recognize that answers to such questions cannot be used to explain the problem away. It is for this reason that we do not ask what characteristics make children susceptible to sexual abuse, and we have long understood that every woman—and probably every man—old or young, beautiful or ugly, is susceptible to rape. Similarly, every individual who enters therapy and who accepts the role of patient may sooner or later be vulnerable to exploitation by his/her therapist.

Close scrutiny of large numbers of patients who have become sexually involved with their therapists confirm that no useful generalizations about victims have yet been identified (Gutheil, 1989; Smith, 1984; Pope and Bouhoutsos, 1986; Schoener, 1989). Based on a survey of the literature and on a population of more than 2000 victims, Gary Schoener and his group at the Minneapolis Walk-In Counseling Center (1989), determined that “no client characteristic predicts sexual involvement with a therapist.” He further notes that characteristics of victims are no different from those seen in the larger patient population. Notman and Nadelson (1994) also conclude from their experience and literature review that “there is no one patient profile.” And empirical data on the more than 500 participants in the Boston-based resourcing and referral network, TELL (Therapy Exploitation Link Line), reveals virtually infinite combinations of psychological and social characteristics. The only unifying attribute is that every participant sought counseling support from a therapist, member of the clergy, or other health-care professional. Despite overwhelming evidence that no useful profile exists, responses to questions concerning the pathology, behavior, and characteristics of victims are warranted if we are to move the discussion forward.

Prior sexual abuse, particularly in childhood, is one factor often proposed to have an impact on patient vulnerability to patient-therapist sex (Kluft, 1990). Of those female victims who have participated in TELL or with whom I have come in contact from throughout the United States, Canada, England, Australia, and New Zealand, there is a self-reported incidence of prior childhood sexual abuse of approximately one-third. This is consistent with the prevalence within the female population-at-large, as indicated by the outcomes of more than half a dozen surveys taken between 1940 and 1987. Three large-scale surveys, a 1983 study by Russell, a 1984 Canadian survey, and a 1985 study by Wyatt, indicate rates of childhood sexual abuse of females at 38%, 28%, and 59% respectively (Haugaard and Repucci, 1989). Boston social worker Nancy Avery, who runs intensive 12-week groups for victims of patient-therapist sex, estimates that 30% of the nearly 120 women she has seen experienced childhood sexual abuse (1994). Cambridge Massachusetts attorney Linda Jorgenson (1994) estimates the rate of prior childhood sexual abuse among her more than 200 clients who have been sexually abused by therapists at “not more than 30%.”

While one might anticipate that the rate of survivors of childhood sexual abuse in the psychotherapy client population would be disproportionate to their presence in the population-at-large, their presence in survivor groups for victims of patient-therapist sex apparently is not. Still, despite survey and anecdotal data, it is difficult to know absolutely whether prior childhood sexual abuse puts a patient at particular risk. The tendency of victims of such abuse to “keep the secret” may make it less likely for them to seek the support of a network such as TELL, a group therapy setting such as that offered by Nancy Avery, or a legal process, in all of which the culture is one of finding and using voice.

Pathological determinants of who is at risk are also highly questionable. The experience of patient-therapist sex so corrupts a personality that attempts, after-the-fact, to reconstruct psychological diagnoses—such as borderline personality or multiple personality disorder—as a way of identifying potential victims, are likely to be seriously confounded. Some patients, for example, may have come into the therapy as a result of trauma. At other times, it is the abusing therapist who inflicts the trauma (Herman, 1992). In both situations, the trauma is compounded by the abuse, creating new and serious problems. Separating cause and effect may take years, and labeling the preexisting condition is likely to do little to move the patient—or an understanding of the impact of the phenomenon—ahead. In addition, documentation necessary for differentiating between pre- and post-victimization personalities is to be found largely in the files of abusers for whom success in discrediting the victim may be essential to avoid losing a lawsuit and licensure.

Attempts at finding a coherent set of commonalities among victims (e.g. Gutheil, 1991) have generally resulted in a list so broad and vague as to be indistinguishable from the larger patient pool. While it is clear that patients who have experienced trauma, who are seeking relief from personal marker events such as life-threatening illness or loss of spouse, or who have severe pathology, may be extremely vulnerable and needy in therapy settings, no abuse occurs in the absence of therapist intent.

Ironically, those patients most likely to become victims are those who, at the outset or over time, come to trust totally in the therapist and the therapy. Patients who suspend such belief and trust may be less likely to be victimized, but they may also be less likely to benefit from therapy. This makes the problem of patient-therapist sex not just the problem of the “bad guys.” Practitioners, the majority of whom are honorable and truly want to help their patients, are unfortunately thwarted in their efforts to be effective ,as trust in their profession is undermined.

The “who” question, then, is highly unsatisfactory and of little use when the response is “anyone who happens to be in the wrong place at the wrong time.” It affords us little insight into what happens and how. It is from a close examination of the process by which victims are drawn into inappropriate relationships with their therapists, as well as from an understanding of the outcomes and the patterns of healing, that useful generalizations may be drawn.

Among the most common yet lingering misconceptions is that patients initiate patient-therapist sex by their own seductive behavior. I categorically reject this as a valid explanation or justification for patient-therapist sex. The term “seductive” is an interpretation of behavior based on an observer’s perceptions. As with any other form of behavior displayed by a patient, it is to be analyzed, not acted upon. Just as beating a masochistic patient would never be justifiable, sex with any patient, even one perceived to be seductive, is also wholly unacceptable.

In my experience, it is far more likely to have been seductive behavior by the therapist that set the process in motion. The overwhelming majority of victims with whom I have come in contact report having felt little if any sexual attraction or interest in a sexual relationship until the seeds of eroticism were planted by the therapist and systematically focused on him/herself. The patient is then drawn into the sexual relationship, not because of a need for sex, but rather out of the need to be valued and to feel good. What is seductive to the patient is not the therapist’s good looks or sexual prowess. It is the potential for a singular and close relationship with an individual who ostensibly has the power to calm and to cure.

The comments of Barbara G. reflect a common victim experience. During a session in the third year of her three-time-per-week therapy, Barbara observed that her therapist, Dr. T, seemed particularly distracted. She says: "I was concerned about him. He always had been so wonderful to me, like a kind old father, and he made me feel like I was someone special. I knew that he had been having problems with his marriage….He had two old dogs that he loved. He had spent a lot of time telling me how worried he was about having to put them to sleep. But when I asked him what was wrong, he just looked at me sadly—sort of wistfully— and told me, ‘I was just thinking how warm and good it would feel to be inside you.’"

Barbara was taken aback, seeing the comment as out-of-context but none-the-less stirring. For the following three years, she and Dr. T. engaged in an escalating pattern of sexual touch, hugging, kissing, and ultimately having sexual intercourse. For Barbara, the sex was a way to maintain the specialness of the relationship, although she felt increasingly shamed and deceitful by the duplicity of her life.

The experience of Carrie C., a 56 year old social worker who sought therapy after the cancer death of her husband, is also typical: "Even though I worshipped Dr. E___, I found him almost repulsively unattractive; but at some point he started asking me and then telling me that I was having sexual fantasies about him. One night, a few months after he had started to say these things to me, I had an erotic dream about him, and I thought, ‘he must be right,’ and then I began to want him—almost obsessively—even though I still found him unattractive. I stopped putting my energy into dealing with my husband’s death and turned all my attention to finding ways to have sex with Dr. E____."

Carrie continues to blame herself for what occurred, adding, “It was my fault; I wanted him so badly. It’s so embarrassing to think about a woman of my age throwing myself at him the way I did.”

In retrospect, both Barbara and Carrie have been able to understand that their abusers set the stage for having sex long before their overtly seductive comments. The slide down this “slippery slope,” from professional relationship to sexual exploitation, may begin at any point in the therapy with the stretching and breaking of professional boundaries. Early on, such boundary violations are mild incursions, unrecognizable by the patient and just as elusive to third-party professionals (Simon, 1989; Strasburger, Jorgenson, and Sutherland, 1992). When viewed in isolation, incidents such as moving the patient to the last time slot of the day, occasional self-disclosure by the therapist, off-hand comments about other patients, or use of flattery, may be deemed innocuous or seen as therapeutic. The therapist’s self-serving interpretations of boundary violating events are accepted—even as the events increase in frequency and intensity—as the patient struggles to reduce cognitive dissonance or as a result of blind trust and a lack of understanding of the therapeutic process. In addition, the patient’s questions about the events are turned away by reassurances of the patient’s specialness to the therapist and admonitions that if the therapy is to succeed, it is necessary for the patient to trust the therapist unconditionally.

By the time the structure of the therapy has dangerously broken down, and the boundary violations have lost their subtlety, the patient has been lulled into believing that he/she is truly special in the life and practice of the therapist and that the therapist is all-powerful and all-knowing. So indoctrinated is the victim, that even after the sexual relationship has continued for a lengthy period, its meaning remains lost to the patient. In one Massachusetts case (Board of Registration in Medicine v. Edward M. Daniels, 1991), the victim returned to the abusive therapist after a hiatus of nearly a year.

I went stating…that it was absolutely vital that we not be sexual, that my now husband and I…are just in the beginnings of a new life…and that I couldn’t risk hurting him, that I had promised him that I would not be sexual with Dr. D___. And he proceeded to be very seductive and to seduce me into being sexual….The whole time I kept saying, “we’ve got to stop, we’ve got to stop. I can’t do this” (pp. 92-93).

This patient continued to see Dr. D for several years. To protect herself, she brought her children to therapy sessions and had them sit in the waiting room.

The set up for the sexual relationship rarely, if ever, results from a single factor. Instead, multiple and inextricably intertwined dimensions make up this complex dynamic. These include, but are not limited to, self-aggrandizement by the therapist, role reversal, undermining the patient’s support systems, stripping the patient’s personal power, nurturing increasing dependency, insisting upon secrecy, and revealing confidential information about other patients. The abuser’s orchestration of this process is often exquisite and may take years or be completed within weeks, depending upon the vulnerability and neediness of the patient.

In my own case, sexual relations did not begin with Dr. S during the first three years of therapy, although it is clear in retrospect that we had progressed well down the slippery slope. During my sessions, Dr. S often focused on my sexual needs and fantasies despite my interest in pursuing other topics. He frequently took telephone calls from other patients, after which he made caustic comments or revealed their names or other material about them. During one period, Dr. S took numerous phone calls concerning the importation and delivery of his new green Jaguar sports car. Adding to the picture was Dr. S’s collection of exotic pets, about which he liked to talk. On several occasions, his owl regurgitated chicken bones onto the office floor, and at one point, a snake escaped from its terrarium and slithered across my feet.

I returned to Dr. S a year after termination, when my husband, a psychiatrist, was shot by a patient. With my husband comatose and dying, Dr. S made his move, but even then it was an elegant manipulation. At the end of each session, he walked across the office to the door, holding it open only wide enough for us to be required to make physical contact as I left. His suggestions of his physical availability began with subtlety but became more overt. He changed my therapy time to allow for an extra half hour, and his self-disclosures became more frequent and more engaging.

I spent the first year of my widowhood, at age 30, performing oral sex on Dr. S. At the time, as I have since learned, he was also sexually abusing students at Wellesley College. Dr. S acknowledged, when I asked, that he had had similar relationships with other patients. He was not concerned about being caught, he said, because, “I pick my people carefully.”

In a 1992 case before the Massachusetts Board of Registration in Medicine (Board of Registration in Medicine v. Joel Feigon, M.D.), Patient A, a psychiatrist, testified that sexual intercourse with her analyst did not begin until several years into her therapy and shortly after she underwent a hysterectomy: "…he said that he loved me. He said that he would help me to feel like a woman…I felt like it was part of my treatment…I felt comfort and solace…I worshipped Dr. F___, and I felt that he had all that was good and that was healing. And that, when I was close to him, it was as if I were at the right hand of God, and I felt blessed to be…close to him" (pp. 75-77).

Well before a patient-therapist relationship reaches this point, the patient has been convinced, through regular reinforcement, that if healing is to take place and the specialness of the relationship is to continue, it is necessary to keep ‘the secret.’ Again, Patient A (Board of Registration in Medicine v. Joel Feigon, M.D.): “It was my understanding from Dr. F___ that what happened in the treatment hours belonged in the treatment hours, and was not to be discussed if this healing was to take place…. My analytic hours were separate from my life in the world, and…it was like I was two different people” (pp 80-81).

In another case, a therapist imposed monetary fines of up to $500 per violation on a patient who discussed her therapy outside of the therapy session. The patient, a single mother of two children, was told that the only way she would understand the importance of keeping therapy confidential was through punishment that was meaningful.

Without power, there is little any therapist can do to bring about submission to the demands described. That the therapist is more powerful than the patient is a truism, but it is probably also as it should be. Therapists without power can do little to help a patient move from sickness to health. The late Dr. Franz Ingelfinger (1980) wrote: "If the physician is to be effective…it follows that the patient has to believe in the physician, that he has confidence in his advice and reassurance, and in his selection of a pill that is helpful…Intrinsic to such a belief is the patient’s conviction that his physician not only can be trusted but also has some specialized knowledge that the patient does not possess. He needs, if the treatment is to succeed, a physician whom he invests with authoritative experience and competence. He needs a physician from whom he will accept some domination…I do not want to be in the position of a shopper at the Casbah who negotiates and haggles with the physician about what is best. I want to believe that my physician is acting under higher moral principles and intellectual powers than a used-car dealer."

While the ability to use power to bring about healing is the mark of the effective therapist, enhancing and extending personal power appear to be driving forces for many abusive therapists. This is achieved through a variety of subtle and not-so-subtle manipulations that are calculated to undermine the patient’s ego strength and widen the gap between controller and controlled. Many victims do research or writing for the therapist’s professional papers, run errands, do house or office work, or otherwise serve their abusers. The ultimate measure and acknowledgment of the therapist’s power and control is sexual servitude, often—but by no means always—in the form of the patient performing oral sex. Patient-therapist sex is rarely accompanied by physical violence, although threats, face slaps, shoving and shaking the victim, and reading and acting out of sado-masochistic material have been reported. Patient-therapist sex is an enslavement of the mind: Enslavement of the body is a symbolic reminder of who controls the mind.

In furtherance of the abuser’s goal of dominance, many victims report being subjected to humiliation and debasement. To accomplish this, the patient is led to believe that the sexual relationship is a generous gift given in response to the patient’s—not the therapist’s—wanton desires. In a 1991 Massachusetts case (Board of Registration in Medicine v. Edward M. Daniels, M.D., 1991), Patient A described the overwhelming power of her abuser and her most painful acts of servitude: "Dr. D___ used condoms. And he insisted that I buy those condoms…that was one of the most humiliating parts of the whole thing for me…because I was very embarrassed and very terrified to walk into drugstores to have to buy condoms….He would put them into a Kleenex and…wad them up and then he gave them to me to go into his bathroom to flush them down the toilet. And he stood there to watch to make sure I did it, but he never walked out with them himself" (p. 93).

Isolation of the patient from sources of support other than the therapist appears to be virtually universal in cases of patient-therapist sexual abuse. “As long as the victim maintains any other human connection,” writes Judith Herman, “the perpetrator’s power is limited (Herman, 1992, p. 79). This isolation is methodical. Gail G., experiencing the beginnings of commercial success as an artist when she entered therapy, describes the process poignantly: "First he told me that if I was going to get well I would have to stay away from my parents. He kept pointing out to me that every time I spent time with my family, I’d get depressed….I started to date someone, and he told me that I should stop going out because the guy wasn’t good enough for me….Then he told me I didn’t have any talent and that I should find something to do I could be good at….In the end, all that was left was him."

Gail gave up her hopes of a career as an artist; she is now a librarian.

Abusers also isolate their victims with constant reminders of the dangers of disclosure. In a Massachusetts case, Patient D, a psychiatrist, described her intense sadness at the destruction of the previously close and supportive relationship she had had with her spouse and children.  At the time, she was unable to understand the connection between the loss of this and other support systems to the abusive relationship, nor was she able to stand up to the therapist’s manipulation and blackmail. Said Patient D (In the matter of Edward M. Daniels, M.D., 1991): "I…told him that he should never have let it happen. And he said that I was right. It was his responsibility. He should not have let sex occur between us and/or sexual contact….I said to him ‘I do not know what I am going to do about it,’ and he said, ‘well, you have to do what you have to do, and I will have to take the consequences.”…I was still not seeing this as sexual abuse….However, he would still suggest that I say nothing to my husband about it because he had seen marriages break apart over things such as this" (pp. 51-52).

An additional and alarming dynamic appears to be emerging in the preliminary findings in a study of 135 victims. Estelle Disch (1994), a principle researcher in the project, has identified a ‘programming for suicide’ by therapists of their victims. “It’s part of the set-up of powerful dependency and isolation,” says Disch. “For the patient, what feels like nurturance also carries with it the message, ‘you can’t live without me.’ It may represent a death wish towards the patient, particularly when the therapist wants to end the relationship. When the relationship ends, the patient takes this message to heart and seriously contemplates and often attempts suicide.” These findings are consistent with and give a new understanding to the high rates of suicidality reported by participants in the TELL network.

When the abusive relationship ends, recognition of the damage and the beginnings of healing may be delayed for prolonged periods, often a decade or more. Denial, ambivalence, guilt, shame, and misinterpretation of the events that took place in the abusive relationship all play roles in keeping the victim from moving ahead. False Memory Syndrome is not an issue. “In over 4000 cases,” says Gary Schoener (1994), “this has never been part of our experience.” While I am aware of several cases in which patient-therapist sex surfaced and brought new and horrific meaning to the previously dissociated events of earlier childhood sexual abuse, victims abused by therapists have continuous memory of what took place. The failure to put the pieces together in such a way as to understand their meaning, or the victim’s questioning of his/her own sense of reality, is sometimes misinterpreted and viewed as the experience having been repressed. In fact, it is almost always the case that victims are able to recall events of the abuse in minute and specific detail. In addition, many victims retain extensive memorabilia from the relationship, and these serve as tools for retaining the details of certain events. I have notes and postcards sent to me by Dr. S. A TELL participant has numerous photographs of her abuser, including one of him seated in a lounge chair, wearing a bathing suit. She took it in her back yard.

Bringing focus to these details is often aided by having the victim write an extensive account of what took place. While this is painful, victims who have been required to undertake such a writing process, usually in conjunction with pursuing a legal claim or proceeding before a board of registration, almost always cite it as an important step in moving healing forward.

It is not until the damage is recognized that healing can begin. This may be a slow dawning or a sharp revelation. Asked what had finally prompted her to come forward after nearly 25 years, one victim gave the following explanation (Board of Registration in Medicine v. Edward M. Daniels, 1991): "It was…a confluence of events and these sort of came together and broke through what I can only look at now as real protective denial…the first event was coming to trust M____ (her subsequent treater) and having him…take seriously what happened….he spent a great deal of time focusing on…that relationship and its impact on me and its meaning in my life. The other factor was that my husband and I separated…and I had rented a house on the Cape and went down there by myself and really began to think about things that I probably had not thought about before. The third thing and probably the most…proximal event was reading…a story in the Globe about a lawsuit or Board of Medicine hearing….the victim…allowed her name to be used….I thought, my God, this is the first time “victim” occurred to me, that other people have had this happen to them and see it as damage" (pp 78-80).

What follows recognition of damage is a process that generally takes not less than three to five years and that defies neatly packaged stage theories. Healing is erratic and highly sensitive to outside forces. It may be halted, or the victim may be pushed back into denial at any point by lack of validation or rejection of the importance of the experience. It is the relational aspects, most notably breach of trust and the assault on the victim’s self-esteem, from which the victim must heal. For this reason, damage to victims whose abuse stopped short of becoming overtly sexual may be as great or greater than that suffered by victims whose abuse included intercourse, fellatio, or sodomy. The victim whose abuse was non-sexual often has a difficult time having his/her experience validated: Family, friends, and subsequent treaters tend to minimize the meaning of the experience. Even when sex did occur, otherwise sympathetic individuals may become anxious and unwilling to engage in meaningful dialogue or supportive action. One victim (Board of Registration in Medicine v. Edward M. Daniels, 1991), told by her subsequent treater that her sexual relationship with her previous therapist had been inappropriate, relates the following: "I had two reactions. One was to wonder if she was right. The other was that she told me she was so upset by what he did that she was going to call him. And each week, I came in and said, “Have you called him?” and she told me ‘no.’ “Oh dear, I haven’t gotten around to it yet, but I will do it this week.” After that happened four or five weeks in a row, I just dropped it. So then I felt like, well, it really must not be that important after all" (p. 88).

For those victims whose abusive relationships took place in adolescence, as in situations in which the abuse stopped short of becoming physical, outside forces often discourage moving ahead. Friends, family, and subsequent treaters commonly respond to the victim’s experience with comments such as, “It happened so long ago—why don’t you just get on with your life,” and “So what? Nothing really happened.” These victims may face years of being thwarted in their attempts to be heard and believed. For some, validation of the importance of the experience becomes life’s central focus. As this happens, the damage done by the original relationship is greatly exacerbated. Many such victims extend their feelings of helplessness and hopelessness to encompass their entire lives.

At point of recognition, the patient’s ambivalence is still strongly tilted towards idealization of the abuser. Self-blame is the norm, and belief that it was the victim’s personal flaws that drove the relationship to termination may continue well into healing and often beyond.

For those victims for whom moving ahead is possible, reconstruction and reinterpretation of the events of the therapy must take place. This happens with a combination of intense anger and sadness as the victim begins to recapture the cues he/she had pushed aside or misinterpreted during the move down the slippery slope. Assignment of a new therapy time, the giving of small gifts, or discussions that took place about the therapist’s marital problems take on new meaning. They are no longer seen as signs of specialness; instead they are recognized as elements that intruded upon and distracted from the real work of the therapy. As this is increasingly confirmed, the victim begins to mourn the loss of time. The abusive relationship is finally understood as having held the victim in place, often for years, during which those around him/her pursued their education, got married, had children, and developed careers. The statement, “I lost my childbearing years” is often heard. Subsequent child adoption, mid-life pregnancy, return to school, or reconnection with former partners are not uncommon.

In the midst of the reinterpretation of the therapy, reassessment of the abuser begins as well, and for a while the two take place concurrently. During this reassessment, the victim begins to perceive the abuser’s actions to have been purposeful and manipulative. When this happens, ambivalence turns to vilification and fury, and the full attention of the victim is given over to the abuser. In time, the victim no longer refers to the relationship as “an affair,” but rather sees it as exploitation and abuse. The perpetrator is no longer unequivocally adored, and fantasies of revenge begin to emerge .

As reinterpretation and reassessment proceed, the rage of the victim may become overwhelming and frightening, not only to the victim’s family and friends, but to the victim as well. Murderous feelings may be turned inward, prompting self-destructive and suicidal behavior. Just as frightening is the random turning outward of anger. When this happens, eruptions are unpredictable and uncontrollable. “I screamed at a waitress,” says Mary M. “All she did was ask me what I wanted to order, and I screamed at her, and kept screaming and using the F word, and then I wondered why I had done that, and then I realized I was so angry, and it had to come out somewhere.” Victims find themselves letting fly at children and mates, and many marriages that managed to survive through the period in which the patient-therapist sex took place fall apart in its stormy aftermath. In horror, the victim begins to wonder whether the pronouncements of the perpetrator—that the victim is “crazy”—might not be valid.

Acknowledging the legitimate basis for the victim’s anger is important, but gauging the right amount of supportive encouragement is often difficult. Joining in the victim’s anger may be counter-productive, frightening the victim who is not ready to confront the depths of that anger and who wants to hold on to some shreds of the relationship, particularly if it has not yet been replaced. The victim’s needs may differ virtually minute to minute, resulting in a wild chaos that undermines credibility and produces stress in those who might otherwise be supportive. Subsequent treaters, and even those in the victim community, often find it difficult to cope with the extremes of recovering victims. At support group meetings, the broadcasting of anger provokes anxiety. Those participants further ahead in the healing process often distance themselves from what they fear may be perceived by outsiders as representative of all victims. If the emotions and needs of victims are disturbing to professionally-trained therapists, another victim’s distress can be overwhelming to a victim struggling to gain control over his/her own life. In support groups without strong leadership, the threat posed by the fragility and volatility of victims often spells the group’s demise.

Anger is an inherent part of the healing process, but it must be analyzed and focused if it is to be productive rather than destructive. Vehicles for focusing anger may include writing a detailed account, becoming politically involved, filing a law suit, filing a complaint with a licensing board, speaking out in a support group or to the press, confronting the perpetrator, or a combination of these. It is critical that the victim be aware of the benefits and drawbacks of the various options and have full control over the choice of what to do and when to do it. Civil litigation and licensing board complaints are long and adversarial situations in which the patient may feel reabused. If the victim is struggling with self-blame and ambivalence, attempts by defense attorneys to discredit the victim may cause severe set-backs (Finnegan, 1994). Similarly, the often volatile dynamics of support groups may compound anxiety, and confronting the perpetrator may resurface feelings of helplessness and dependency or intensify the sense of loss. Never-the-less, the benefits of taking the action at the appropriate time are almost always greater than the downside risks.

Taking action is an important adjunct to—but not a substitute for—therapy. Participation in a support network, for example, helps the victim validate his/her experience and break the isolation. Meeting other victims is a powerful experience that often proves pivotal to the healing process. Meeting another victim of the same abuser through a support network is the victim’s most powerful desire and greatest fear. When it happens, it puts to rest the last fantasies about the specialness and exclusivity of the relationship. However, it also compounds the sense of betrayal and guilt. One victim described the experience as “It was like finding a sister I never knew I had and finding out that we had both had sex with our father. Then I felt guilty that I hadn’t done anything to keep it from happening to her, but I was also angry that she hadn’t done anything to keep it from happening to me.”

When victims meet victims, or take other action, it is important for subsequent treaters to both recognize the importance of the experience and also to help the victim process its meaning. At the outset of every TELL meeting, it is expressly stated that:”TELL is not a therapy group but a place for victims to meet and support one another. TELL also provides an opportunity to learn, give information, and come to understanding and healing by listening to one another.”

Facilitators of TELL meetings strongly recommend that participants seek to establish a trusted therapy contact so that when difficult or painful issues arise, there will be an additional place to get support.

During the action phase, a subsequent treater should help the patient gain perspective on what he/she is feeling and make clear that the decision on whether to proceed and at what rate is within the patient’s control. The one exception to taking action being within the control of the patient relates to the statute of limitations on civil litigation, which varies from state to state and which may be tied to the point of recognition of damage. If, for example, the statute limits legal action to taking place within a three year period from the point of recognition, discussion of the abuse with a subsequent treater may start the clock. Subsequent treaters should be aware of the laws and the options and be able to direct their patients to knowledgeable resources.

Unfortunately, subsequent therapies are often doomed by the inability of victims to form therapeutic alliances, as well as by failure of the subsequent treater to understand the abusive experience. Many victims go “therapist shopping,” as they struggle to find someone with the right mix of anger, clarity, and grief over what has taken place. In the words of one victim: “I think I probably selected him out of the number of people I saw because when…he asked me and I told him in that first interview, his eyes filled with tears. I didn’t know at that time that that was why I was picking him, but I’m certain it was….”

If a therapist shows signs of disbelief or attempts to place blame on the patient for what occurred, the patient will almost definitely not return. Moreover, the same may be true when the therapist absolutely believes the patient and displays extreme anger at the perpetrator or is preoccupied with taking action. Sometimes victims will flee subsequent treatment, even if the therapist has done everything right, simply because the victim is not yet ready.

No statement from a subsequent treater will provoke patient flight faster than, “you’ll just have to trust me.” Undoubtedly, this was an underlying theme of the abusive therapy. Recognition by a subsequent treater that there is no reason for the patient to trust in either the therapist or the therapy is critical. In the words of one victim, Diane M., “I had gone through seven different therapists and finally concluded that if I had to trust someone, I would never get anywhere. I decided to give up on trusting and just work on the issues” (Wohlberg, McCraith, and Thomas, 1999).

Victims in subsequent treatment may display decentralized symptoms that include extreme anxiety, desperation, and helplessness. They may be exceptionally demanding, needing constantly to have the therapist’s commitment reinforced, and they regularly test boundaries, praying violations won’t occur but convinced that they will. When boundary violations are perceived by the patient in subsequent treatment, they both confirm the patient’s fear that no therapist is to be trusted and also reinforce the belief, instilled by the abusing therapist, that it was the patient’s powerful desires that caused the abuse in the first place. Ruth N. is a 46 year old school teacher whose abuse was in the form of financial scamming. It began eight years into her therapy, after she had successfully settled a major lawsuit. Says Ruth, “I don’t know what I do to people. Dr. M___ was so wonderful to me. I thought he was God. What did I do to change him into the person he became?”

An analytic patient (Thomas, 1993) offers another insight into the victim’s fears: "…after my third session…I vividly remember telling him boldly, “I’m going to get you, Dr. K.”….I have come to understand how, unconsciously, I was setting the stage to test whether my relationship with Dr. K. would be safe, or if I would be able to seduce him like I felt I had done with my previous male therapist….Repeatedly, I have tested whether or not I could trust Dr. K…by a highly sexualized transference and the expression of intense rage. Frequently, I have raised provocative material, to see if I could get a ‘rise’ out of him, literally, and to see if he would act on his sexual desires. When I failed to get him to respond…I would become sadistic and abusive.…It has been a Herculean task for me and Dr. K to establish and maintain a trusting and safe therapeutic relationship, in which I can feel free to say whatever is on my mind and not fear that my wishes and fantasies will be taken literally and acted upon."

Subsequent treaters who become reactive to the patient’s boundary testing or anxious over the revelation of a patient’s prior abuse may unwittingly push the victim to tell the story in an acceptable, but not necessarily useful way. This may include repositioning the emphasis of the story away from the patient’s feelings of betrayal and focusing instead on the patient’s anger. It also may include rejecting the victim’s positive feelings about the abuser, feelings that need to be validated along with the sense of loss.

Ultimately, with the help of appropriate support systems, the victim may move through the process of healing and come to accept that the abuser is a flawed individual who also may have done some good. Far more than a forgiveness of the abuser, healing involves a forgiveness of self, an understanding of how the events of the abuse came about, and a release from shame.

Given all of this, what is it that we in the victim community really want—from subsequent treaters, the mental health community, lawyers and legislators, abusers, and ourselves?

From subsequent treaters, we want validation, as well as clear and safe boundaries. We want therapy that empowers us through shared control and an acceptance of our need to make our own decisions about our lives. We want recognition and acceptance of our ambivalence towards our abusers, and we want an atmosphere in which we are encouraged to build open and honest relationships beyond the limits of the therapy. Finally, we want therapy that extends our options beyond those that we can think of on our own.

From the mental health community, we want recognition that patient-therapist sex happens, that when it does it is harmful, that it is never “okay,” and that it is always the responsibility of the therapist. We want cessation of attempts to closely categorize victims with such terms as “borderline,” and a recognition that such categorization does little more than blame the victim. We would like you to recognize, as we do, that patient-therapist sex is never really going to go away, and that by sticking our heads in the sand, we are only becoming less dignified and more obvious targets. We would like recognition that patient-therapist sex is a shared dilemma in which therapists and victims experience many common feelings, i.e., we have both been betrayed by people we trusted; we both feel shame and anger over what has taken place; we both feel confused; and we are both struggling to know what to do with information about sexual abuse once we have it. We would like you to recognize that among you are many of the same people who are among us: that therapists are often victims of patient-therapist sexual abuse; that perpetrator’s justify this abuse under the guise of collegiality; and that the victims among you fear that sharing their experience will cause them to be labeled in the pejorative terms often used to describe the rest of us. We would like you to free them from censure, give them communal support, and look to them as resources for building understanding about how patient-therapist sex happens and why. We would like opportunities to work with you to move beyond bland or intellectualized characterizations of the phenomenon into substantive dialogue and action. We would like to support you and for you to support us in becoming educated about therapy and the meaning and impact of patient-therapist sex. Finally, we want the mental health community to take responsibility for cleaning up its act out of a recognition that it is its own errant members—and not the victims—who are undermining the public’s trust in therapy and therapists.

From our legal system, we want defense and plaintiff’s attorneys alike to refrain from pressuring victims to sign gag orders; and we want recognition that silencing victims is not only counter to the best interest of the victim but also inconsistent with the public interest. We do not expect lawyers to stop defending their clients, and we are aware that as the patient-therapist sex phenomenon receives more public attention, false claims—now a rare occurrence—could become more common. However, we would like recognition that patient-therapist sex is always the responsibility of the therapist and that harassment and threats of embarrassing disclosures of irrelevant material, such as a victim’s past sexual history, are not acceptable and serve neither to further justice nor truth. While we would prefer the field of psychotherapy to be self-regulating, if this is not possible, we would like at least minimum standards and appropriate oversight of quality imposed by government regulation.

As victims, we want to emerge free from the secret and the shame. We want our power and our voice. We want the ability to be the nurturing, caring, and trusting human beings we once were. We do not want revenge, but we do want to prevent our perpetrators from doing what they did to us to anyone else. We want the ability to forgive and move on, recognizing that through the experience and the process of healing, we have found strengths we never knew we had.

Once we have truly healed, most of us no longer have any expectations of our perpetrators. We recognize that they are seriously impaired individuals who should find other careers, since they are unlikely to have the capacity for rehabilitation.

So what is it that victims really want? Psychotherapist and victim Laverne MacInnis offers the most succinct yet all-encompassing response. “Well,” she says, “to begin, an apology would be nice.”

References:

Avery, N. (1994), Personal communication.

Board of Registration in Medicine (Mass.) v. Edward M. Daniels, M.D., Docket #RM-90-939, pp. 92-93 (1/22/91).

Board of Registration in Medicine (Mass.) v. Edward M. Daniels, M.D. Docket #RM-90-939, 93 (1/22/91).

Board of Registration in Medicine (Mass.) v. Edward M. Daniels, Docket RM-90-939, 78-80 (1/23/91).

Board of Registration in Medicine(Mass.) v. Edward M. Daniels, Docket RM-90-939, 88 (1/23/91).

Board of Registration in Medicine (Mass.) v. Joel Feigon, M.D., Docket RM 90-1304, 75-77 (1/27/92).

Board of Registration in Medicine (Mass.) v. Joel Feigon, M.D. Docket RM 90-1304, 80-81 (1/27/92).

Disch, E. (1994), Personal communication: Based on preliminary findings by Disch and Avery, Sexual involvement/exploitation between health and mental health care providers and their clients: effects on clients.

Finnegan, M. A. (1994), Presented at the September 9 meeting of TELL, Newton, MA.

Gutheil, T. G. (1989), Borderline personality disorder, boundary violations, and patient-therapist sex: medicolegal pitfalls. Amer. J. Psychiat.146:5, 597-602.

Gutheil, T.G. (1991), Patients involved in sexual misconduct with therapists: Is a victim profile possible? Psychiat Annals 21:11, 1-7.

Haugaard, J.J. & Repucci, N.D. (1989), The Sexual Abuse of Children. San Francisco:Jossey-Bass.

Herman, J.L. (1992), Trauma and Recovery. New York: Basic Books.

Ingelfinger, F.J. (1980). Arrogance. N. E. J. Med. (26) 303:1507-1511.

In the matter of Edward M. Daniels, M.D., Adjudicatory Case No. #91-3-DALA (Mass.), 51-52 (1/24/91) .

Jorgenson, L.M. (1994), Personal communication.

Kluft, R.P. (1990), Incest and subsequent revictimization: The case of therapist-patient sexual exploitation with a description of the sitting duck syndrome. In: Incest-Related Syndromes of Adult Psychopathology, ed. R.P. Kluft. Washington, D.C.: American Psychiatric Press.

Notman, M.K. & Nadelson, C.C. (1994), Psychotherapy with patients who have had sexual relations with a previous therapist. J. Psychother. Prac. & Res. 3:185-193.

Pope, K.S. (1990), Therapist-patient sexual involvement: A review of the research. Clin. Psychology Rev., 10:477-490.

Pope, K.S. & Bouhoutsos, J. (1986), Sexual Intimacy Between Therapists and Patients. New York: Praeger.

Schoener, G.R. (1989), A look at the literature. In: Psychotherapists’ Sexual Involvement with Clients: Intervention and Prevention, ed. G.R. Schoener, et al. Minneapolis: Walk-In Counseling Center. p. 45.

Schoener, G.R. (1994), Personal communication.

Simon, R.I. (1989), Sexual exploitation of patients: How it begins before it happens. Psychiat. Annals 19:2, 104-112.

Smith, S. (1984), The sexually abused patient and the abusing therapist: A study in sadomasochistic relationships. Psychoanal. Psychology, 1:2, 99-112.

Strasburger, L.H. Jorgenson, L., and Sutherland, P. (1992), The prevention of psychotherapist sexual misconduct: Avoiding the slippery slope. A. J. Psychother., 46:4, 544-555.

Thomas, D. (1993) Presented at the annual meeting of the American Psychiatric Association, San Francisco.

Wohlberg, J.W., McCraith, D.B., and Thomas, D.R., Sexual misconduct and the victim survivor: A look from the inside out.” In Bloom, JD, Nadelson, CC, and Notman, MT., eds. Physician Sexual Misconduct. American Psychiatric Press, Washington, D.C., 1999.

© Copyright 1997 Janet W. Wohlberg

To return to the list of all Papers, click here.