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Privacy and Confidentiality in the Therapeutic Relationship

Appendix - FAC 64B4-10.002-10.004 Sexual Misconduct
(Regulation is reprinted at the end of this section)

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FAC 64B4-10.002 Definition of Sexual Misconduct
Summary of Changes

The changes in the regulations are as follows.
Summary of changes...
The only version currently on the Internet is for 2018.

2018 FAC 64B4-10.002
FAC 64B4-10.002 Definition of Sexual Misconduct
(1) It is sexual misconduct for a psychotherapist to engage, attempt to engage, or offer to engage a client in sexual behavior, or any behavior, whether verbal or physical, which is intended to be sexually arousing, including kissing; sexual intercourse, either genital or anal; cunnilingus; fellatio; or the touching by either the psychotherapist or the client of the other’s breasts, genital areas, buttocks, or thighs, whether clothed or unclothed.
(2) It is sexual misconduct for a psychotherapist to encourage the client to engage in sexual conduct with a third party unless:
(a) Such encouragement is consistent with the planned treatment of the client’s specifically diagnosed mental, social, or sexual dysfunctions or disorders; and,
(b) Treatment is provided in accordance with generally accepted professional standards for psychotherapy in this State.

FAC 64B4-10.003 Psychotherapist-Client Relationship
Summary of Changes

The changes in the regulations are as follows.
Summary of changes...
The only version currently on the Internet is for 2018.

2018 FAC 64B4-10.003
A psychotherapist-client relationship is established between a psychotherapist and a person once a psychotherapist renders, or purports to render, clinical social work, marriage and family therapy or mental health services including, but not limited to, psychotherapy, counseling, assessment or treatment to that person. A formal contractual relationship, the scheduling of professional appointments, or payment of a fee for services are not necessary conditions for the establishment of a psychotherapist-client relationship, although each of these may be evidence that such a relationship exists.
(1) Sexual misconduct, as defined in Rule 64B4-10.002, F.A.C., with a client is prohibited.
(2) For purposes of determining the existence of sexual misconduct the psychotherapist-client relationship, once established, is deemed to continue for a minimum of 2 years after termination of psychotherapy or the date of the last professional contact with the client. However, beyond that 2 year time period, the mere passage of time since the client’s last visit with the psychotherapist is not the sole determinative of whether or not the psychotherapist-client relationship has been terminated. Some of the factors considered by the Board in determining whether the psychotherapist-client relationship has terminated include, but are not limited to, the following:
(a) Formal termination procedures;
(b) Transfer of the client’s case to another psychotherapist;
(c) The length of the professional relationship;
(d) The extent to which the client has confided personal or private information to the psychotherapist;
(e) The nature of the client’s problem; and,
(f) The degree of emotional dependence that the client has on the psychotherapist.
(3) The psychotherapist shall not engage in or request sexual contact with a former client at any time if engaging with that client would be exploitative, abusive or detrimental to that client’s welfare or if the sexual contact is a result of the exploitation of trust, knowledge, influence or emotions, derived from the professional relationship.
(4) A client’s consent to, initiation of, or participation in sexual behavior or involvement with a psychotherapist does not change the nature of the conduct nor lift the prohibition.

FAC 64B4-10.004 Sexual Misconduct Not Involving Client Contact
Summary of Changes

The changes in the regulations are as follows.
Summary of changes...
The only version currently on the Internet is for 2018.

2018 FAC 64B4-10.004
(1) It is sexual misconduct for a supervisor to engage a supervisee in sexual behavior as defined in Rule 64B4-10.002, F.A.C., during the period a supervisory relationship exists.
(2) It is sexual misconduct for a psychotherapist to engage in sexual behavior as defined in Rule 64B4-10.002, F.A.C., with any immediate family member or guardian of a client during the period of time psychotherapeutic services are being provided to the client.
(3) “Immediate family” shall be defined as spouse, child, parents, parents-in-laws, siblings, grandchild, grandparents, and other household members.

- Florida Department of State. (n.d.). Chapter 64B4 Sexual Misconduct in the Practice of Marriage and Family Therapy, Clinical Social Work and Mental Health Counseling. Retrieved December 27, 2018, from


Sexual Misconduct
Application Example...
Violation of the Therapist Sexual Contact Boundary

We, as therapists, would like to think that mental health professionals taking sexual advantage of their clients is a problem that was left far behind in the free love era of the 70's and 80's and in the AIDS awareness of the 90's. One would certainly feel this is not something to be concerned with, especially in this lawsuit prone new millennium. Don't you hear at least one advertisement per night on television from a lawyer pleading you to sue someone about something?

♦ 3 Rationalizations for Sexual Violation
But the truth is many mental health professions rely on a number of rationalizations and assumptions that allow us to maintain certain beliefs about balancing the power in the therapeutic relationship regarding sexual contact boundary. Here are three I've found. See where you fit.
1. Are you thinking, right now, balancing therapeutic power regarding the sexual contact with clients no longer exists?
2. Do you think that the occurrence of this contact is currently greatly exaggerated?
3. Do you think that we are able to, "so to speak," police ourselves; and that clients who complain are treated with dignity and respect?
I feel beliefs that maintain the silence about abuse of patients, clients, residents, etc. perpetuate these rationalizations.

My belief is that understanding is the first step to learning. My hope is that you feel you have a real interest in learning more about this complex and emotionally laden topic.

Assess Therapist's Self-Talk
Bad Apple, Victim Blaming, and Sexism

If you are uncomfortable with the topic of physical contact boundaries and the balance of power with the mental health professional, take a second to do some honest soul-searching to see if your self-talk falls into one of the following categories.

5 Categories of Therapist Self-Talk

♦ Category #1. The "Bad Apple" Theory
This first one is what I call the "Bad Apple Theory." It goes something like this: therapists who abuse clients are "Bad Apples" that bear no relation to the rest of the mental health profession.
If you feel this way... I feel your belief may be fueled by the few cases of repeated sexual abuse by a professional whose cruel and bizarre behavior seems far removed from that of a caring and compassionate mental health professional.

It's easy to write these people off as sociopaths and take an "us-them" attitude, but, in fact, problems with the "balance of power in the therapeutic relationship" are a perpetual difficulty for therapists. Sometimes the line dividing abuse, impropriety, and unethical professional behavior is blurred. This blur is indicated in the articles found in your Course Content Manual.

♦ Category #2. Do You Want to Blame the Victim?
Secondly, regarding your self-talk and this attitude assessment exercise, at a certain level, do you want to blame the victim? Even when the sexual violation is recognized, we may find ourselves looking at the victim's emotional problems or personality traits. After all, haven't we all counseled clients who are on the borderline of reality that could misconstrue even the most innocent remark or gesture as a sexual violation?

As you may know, focusing on client characteristics is a common strategy used by lawyers who defend sexually abusive mental health professionals. We would like to pathologize the client to such an extent that they appear to exonerate or partially exonerate the professional. I have found, in my practice, a typical description of female clients who were sexually involved with their therapists was often depicted by the opposing council as "hysterical" and promiscuous.

♦ Category #3. Sexism
Thirdly, regarding your self-talk, ask yourself, is sexism involved in your thinking? The old saying, "Hell hath no fury like a woman scorned" seems to underlie feelings of some judges in our court system today. One of my clients, I'll call Mary, was found by the court to be making "false allegations." The court felt these allegations were vindictive acts against her male therapists, whom the court felt Mary perceived as being disinterested and rejecting.

♦ Category #4. Therapists Never Feel Attracted to Clients!
Fourthly, for whatever reason, you may feel that therapists never feel attracted to their female clients. I'm surprised, when I talk with other mental health professionals, because they see therapists as benign, compassionate eunuchs, so to speak, far removed from the trials and tribulations of ordinary people. Some view all therapists as dedicated and nurturing parental figures. Think about it... this belief is carried over into college and university training programs, where there is little or no instruction pertaining to sexual attraction to clients.

♦ Category #5. What is Your Professional Code of Ethics?
Fifth, in this attitude assessment is: what is your professional code of ethics? Do you feel we are totally able to police ourselves, so to speak? Do you feel mental health professions are able to stand apart from their biases, like the ones just mentioned?

'Special Status Role'
Are you the Sun? the Moon? the Stars?

The next question that may arise in your mind is "How can sexual abuse of a client by a therapist come about?" With those clients I've treated who've suffered abuse, I've noticed a certain pattern.

Pattern of Sexual Abuse Victimization

♦ Vulnerability
The victim, who is seeking help for a disorder or problem, may have some vulnerability in addition to being in the patient or client role. For example, in Mary's case, she was going through a divorce. The mystique and authority of the role of the "therapist" created a situation in which she saw the therapists as having some sort of special healing powers. Thus she felt she needed to comply with his directions, advice, and suggestions.

Once the treatment began, the therapist came to have a parent-like importance to her. She described feeling like a young child, anxious to comply readily with her therapist's advice and suggestions. Admittedly, we have all had clients that place us in this role and give their power away to us, thus creating an imbalance.

♦ The Unique Emotional Component - Faith
The relationship between mental health professional and client, as you know, is not just a business relationship. Its unique emotional component helps explain the faith clients have in us. This faith adds to the emotionally charged factors of power, superiority, and self-esteem. The therapeutic relationship gives the professional authority to enter and explore vulnerable aspects of your client's minds.

Conditioned as children to embrace the superiority and power of professionals, some of our clients readily admire their therapist's positions or titles, respect our knowledge, comply with our directions, and defer to our opinions. Because our clients have faith in us as professionals, they believe that they will be taken care of, and make a commitment to us. This added ingredient of "faith" often triggers clients to comply automatically, and without hesitation, causing a dramatic shift in power in the therapeutic relationship.

"He was everything to me..."
This "Special Status Role" accorded to Mental Health Professionals was evident when Mary talked to me about her therapist. "He was everything to me -- sun, moon, stars, mother, father, confessor, everything." She had faith that the professional was a person of honesty and integrity who had only her best interests at heart. In the initial sessions with the therapist, I'll call him Russ, he was able to relieve some of Mary's stress related to her divorce. This reinforced even further for her that the professional had some special healing powers.

Abusive Therapy - A Story of Professional Manipulation
and Mystique

In the case of the power-abusing therapist, a second key to the pattern is that the therapist is usually also going through a life crisis and emotional difficulty that seriously impairs his or her judgment.

Let's focus more now on the case of Mary. Mary shared with me that her therapist stated feeling "trapped in his marriage due to having two children he felt 'talked into' by his wife."

3-Step Progression in the Case Study of Mary

♦ #1. Meeting His Own Needs - Instead of the Client's
However, with Mary, the balance of power shifted to unprofessional conduct when the therapist's responsibility to act only in the client's best interests, gradually began to reframe or reshape the relationship in a way that allowed him to meet his own (rather than Mary's) needs.

Some clients or patients, as you might guess, quickly perceive that they are being treated inappropriately and terminate the therapy relationship. However, others, like Mary, get trapped and may stay in exploaitive or abusive client-therapist relationships. For a time, Mary felt wonderful, viewing herself as special and feeling very nurtured, cared for, and cared about, but obviously what was really happening was quite different.

The professional's manipulation of the situation, combined with his mystique so to speak, and the power imbalance of the professional relationship made the situation more complicated. Combine this with Mary's vulnerability and you can see what kept her in an emotionally detrimental situation. This situation, clearly undermined her mental health and stifled her emotional growth. In addition, needless to say, Mary was not working on her problems or difficulties regarding adjustment to her divorce that took her to the professional in the first place.

♦ #2. How the Abusive Therapy Relationship Ended
You may be wondering, how Mary's abusive therapy relationship ended. When she arrived early for an appointment one day and observed a long embrace between her therapist and another female client, she began to see the true picture and realized the relationship was damaging her and that she must leave.

However, terminating the relationship did not end Mary's problems. She was left with even more difficulties and stress than when she started. Now she had the after-effects of a sexual post-traumatic stress disorder.

Many other obstacles also remained, not the least of which was the lack of support from others in her life. Mary's mother felt that she should have known better and viewed her as merely having had an affair with a married man. Because of her mother's comments, Mary, a 35 year-old, was unable to gather the courage to seek out added help from friends and relatives who may have been supportive. Mary blamed herself and felt ashamed

♦ #3. Finding a Therapist She Could Trust
As you might guess Mary was left with major difficulties regarding trust, and was at first unable immediately to seek further therapy after the incident. When Mary began trying to understand and heal from the damage done to her, she had yet another hurdle to face which was that of finding a therapist she could trust. Mary had received my name via a word-of-mouth recommendation.

Five years after seeing the abusive therapists, Mary had moved twice and came to me blaming herself and feeling deeply ashamed. Her presenting problem was an inability to get along with co-workers, as well as to sustain a long term relationship following her divorce.

Unethical Role Reversal,
Professional Privilege, Double Bind and Secrecy

According to Pinfold, there are four characteristics that separate the normal power imbalance in a therapeutic relationship from an unethical power imbalance.

A normal power imbalance
may exist for you because some of your clients may perceive you as being a "healing guru" so-to-speak. However, the four characteristics of indulgence of role reversal, professional privilege, double bind interlock, and secrecy all set in motion a series of relational changes that create a new system of power with a force all of its own.

4 Characteristics of Relational Power-Imbalance

♦ 1. Role Reversal
Regarding role reversal and shifting the emphasis from helping the client to meeting the professional’s needs, the professional may rationalize to his or herself their behavior by claiming that they are still meeting the clients needs. The client becomes the caretaker, and the professional can now look to the client to satisfy his or her needs, thus twisting the ethics of care. But the professional does not give up the control in the relationship and still defines the boundaries according to his or her own needs.

♦ 2. Indulgence of Professional Privilege
Secondly, regarding indulgence of professional privilege, for instance the professionals needs and the clients vulnerability may combine to present an opportunity for the professional to exploit the relationship. A sense of entitlement may be used to allow the professional to intrude on the client. Mary was told that the sexual contact during the session was therapeutic for her. By engaging in this activity Russ, her therapist, told her she was learning to love again and not hate men.

♦ 3. Double Bind
Thirdly, the double bind is a form of a paradoxical communication that takes place in which the therapist expresses a message that can be interpreted in two, or contradictory, or mutually exclusive ways. Here’s how this double bind worked with Mary. She felt a commitment to action due to the faith she had placed in the therapeutic relationship.

♦ 4. Secrecy
The fourth and final characteristic that separates a normal therapy power imbalance from an unethical power imbalance is that of secrecy. The secrecy element in Mary’s case was played out by scheduling her at the end of the day, after others had left the office. Also at times the therapist would suggest another location for the session, like the therapist’s or the client’s house.

- Peterson, M. R. (1992). At Personal Risk: Boundary Violations in Professional Client Relationships. New York: W.W. Norton.

Therapist's Manipulation:
4 Warning Signs of Client Power Entrapment

Situational factors, or the environment, may play a part in facilitating the onset of an abusive relationship. In pointing this out, I remove no responsibility from the therapist. The responsibility of the abuse lies with the therapist because the removal of constraints is planned by this professional.

♦ 3 Situational Factors of an Abusive Relationship
Here are three examples of situational factors being manipulated by the therapists to remove constraints.
-- 1. First, Mary's therapist told her to make a late appointment, after the secretary had left.
-- 2. Second, he knew that her husband had moved out following the divorce. He invited himself to her home for a "cup of tea."
-- 3. Third, he invited her to his house to read a copy of the play he had written on a weekend, when his wife and two children were in another city visiting relatives.

Regarding the situational factors, it might be interesting to note at this time that the literature suggests the lower incidence of client abuse by social workers as opposed to psychiatrists and other mental health professionals might be attributable to their work situations. The work situation of a social worker working for an agency is often the setting of a busy public office.

♦ Intense Feelings Bound up in the Relationship
A second warning sign, as mentioned earlier, is client vulnerability. Attachment Theory plays a major role here. As you know, children develop attachments to their parents, siblings, and other family members. The quality of these attachments depends on a number of factors, including the consistency and availability of the main parent figure, or "primary caretaker."

As was the case with Mary, during her first three years, she was exposed to repeated parental absence, emotional unavailability, and abuse. She thus developed a tendency for "anxious attachments," with clinging behavior and fears of being separated from significant others. She learned about this abuse from an aunt. This abuse led to her tendency to cling to important others, be possessive, and fear abandonment. As you know, relationships based on such characteristics are sometimes called "symbiotic", meaning that there is a psychological fusion of two people. The symbiotic relationship, or in some cases codependent relationship, allows the person to avoid re-experiencing the vulnerabilities and anxieties of childhood, thus causing a power imbalance with others.

♦ Idealizing the Professional
A person is more likely to form a symbiotic relationship with a mental health professional. As a result, they end up idealizing the professional clinging to them and fearing abandonment. Specifically in the case of Mary, she was unable to leave the relationship, even though it was damaging and exploitative. Kenneth Pope who wrote "Sexual Involvement with Therapists" indicates connections between childhood abuse and symbiotic or codependent relationships with an abusive therapist almost seems to orchestrate the client's enslavement.

♦ The Wish for an Omnipotent Rescuer - A Life and Death Matter
However, many of the clients we treat have had abusive childhoods. What was different in the case of the abused client? The literature seems to incite a traumatic transference often occurs at a certain level. I define a traumatic transference, as an intense, life-or-death quality of the reaction by a survivor of childhood trauma to a person in authority. The survivor's emotional responses have been changed by experiences of terror and helplessness. Abused clients cast the mental health professional in the role of omnipotent rescuer. However, at the same time, they state their mistrust of them. Mary stated many doubts, suspicions, and feelings that she had to try to control the therapist by giving into his sexual advances

4 Warning Signs
No doubt, with Mary, the four warning signs indicated by Pope came in to play:
-- 1. First, Mary's idealization of the professional;
-- 2. Second, her wish for an omnipotent rescuer;
-- 3. Third, her intense feelings bound up in the relationship;
-- 4. Fourth, her impression that the survival of the treatment relationship was a life-and-death matter.

All four of these factors lead to the power entrapment of a childhood trauma victim with an abusive professional.

Typology of Sexually Abusive Mental Health Professionals

Phyllis Chesler, in her book "Women and Madness," indicates victims report that the professionals who abused them were going through life crises or changes. If you recall Russ, the therapist that treated Mary, indicated he was unhappy with his marriage.

Chesler indicated one victim, who felt that her psychiatrist was too familiar during her first session with him, reported that "he kissed me, and asked if he could visit me on his way home." She cancelled any follow-up sessions and later discovered "the psychiatrist was in the process of a divorce."

Josephine, whose female psychologist had recently gone through a marriage breakdown, confided, "She kept telling me that I was uptight about my body. So she suggested that we go to the nude swimming session at the YWCA together. Afterwards, she asked me back to her apartment."

Perfunctory sex was a common experience with abusive professionals, as described by the nine women abused by therapists in the Chesler study. The professional appeared to be interested only in his or her own sexual needs, and had no interest in the emotional or sexual gratification of their patients or clients.

♦ Incest Victims
Chesler states there is a tendency for professionals to abuse incest victims shortly after they disclose their abuse. This could be linked to a perception of the incest victim as having been "publicly deflowered" and therefore no longer deserving of protection or respect. Thus the mental health professional may view the incest victim as "fair game," and may excuse his or her seduction of the client by telling themselves that they cannot do the client any further harm.

The abused child, trained as to please men, may engage in a kind of ritualized seductive behavior that arouses the professional and permits him to believe that she has an adult desire for sex with him. Because the victim has low self-esteem and may believe that no man will care for her without a sexual relationship, she may feel that sexual involvement with the professional is a necessary price to pay for his attention.

♦ Stone's 6 Types of Sexually Abusive Mental Health Professionals
Based on his clinical experience, Alan Stone proposed a typology of sexually abusive mental health professionals. Interestingly, Stone makes no mention of female therapists. We'll discuss his focus on male therapists later. The six types of therapists are as follows:
1. The therapist who is middle-aged, depressed, and has problems in his own marriage. He usually gets involved with a younger female client, to whom he tells his troubles. Sometimes the client is led to believe that the therapist is contemplating divorcing his wife and marrying the client.
2. The manipulative and sociopathic therapist is exploiting his position and its opportunities with a goal of self-gratification.
3. The therapist who uses patients to satisfy perverse instincts. This group includes therapists who drug their patients into unconsciousness and then have sex with them. Unlike the other examples, this does not involve an exploitation of transference, of the patient's view of the therapist as a parent- like figure.
4. The charming, expansive, grandiose therapist who wants to be loved by his female patients, particularly if they are young and attractive. He initiates hugging and kissing early in the therapy, and goes on from there.
5. The therapist who sees himself as "progressive" and believes that this includes sexual contact with his patients.
6. The introverted and withdrawn therapist who is very uncomfortable with interpersonal intimacy. If a patient appears to be intensely sexually attracted to him, he succumbs. He may contend that the patient seduced him, but is likely to feel guilty and will probably confess.

♦ Schoener's 6 Types of Sexually Exploitative Therapists
Another typology of sexually exploitative therapists, again with six categories, has been developed by Schoener and his associates at the Minnesota Walk-In Counseling Center. The clusters are as follows:
1. Naive and uninformed: This group includes trainees and poorly trained therapists who may lack knowledge of professional standards and the importance of boundaries.
2. Healthy or mildly neurotic: Minimal sexual contact or comprises in a single episode leading to remorse and requests for help are common.
3. Severely neurotic: This group has severe, long-standing emotional problems and focus on getting their personal needs met in the work setting. As intimacy grows in a therapeutic relationship, these therapists play seductive games, talk about themselves, use touch excessively, and arrange business or social involvements outside counseling.
4. Character disorders with impulse control problems: These therapists have a variety of problems which may include legal difficulties; they have little or no appreciation of the effect of their impulsive and inappropriate behavior on others, and tend to deny or minimize any harm they have caused.
5. Sociopathic or narcissistic character disorders: These therapists are adept in manipulating clients and professional colleagues; they are cool and calculating, able to cunningly seduce a variety of clients and cover their tracks.
6. Psychotic or borderline personality disorders: These therapists are more obviously mentally ill, with poor judgment and a tenuous grasp on reality.

How do you feel after hearing this list of Stone's typology of sexually abusive mental health professionals? Do you feel a knot in your stomach right now? Is this material difficult for you to hear? I know for me it is because the thought of this existing in our profession is unthinkable.

7 Factors that Contribute to Therapist Sexual Contact

You may ask yourself...How does a normal, healthy therapeutic relationship shift into a power imbalance that results in sexual abuse?

♦ 3 Factors Contributing to the Outcome of Sexual Contact
Various factors contribute to the outcome of sexual contact. These factors can be identified in both the victim and the abusive mental health professional, as well as in the situation itself, which may facilitate the emergence of an abusive relationship. Using Mary's accounts and the professional literature, we will examine the following overlapping concepts:
1. Reframing the relationship
2. Boundary violations
3. Pope's description of ten common scenarios.
This will be followed by a consideration of situational factors, and finally, of special issues for victims of childhood abuse.

In the literature, like other survivors, therapy survivors like Mary frequently experienced a similar kind of manipulation for sex. The abusive professional would gradually reframe or reinterpret his client's childlike dependency on a parental figure. In the course of this reinterpretation, the parent or parental figure would become a romantic or sexual partner.

In her book "Betrayal," Julie Roy describes her therapist teasing her about having a "bathtub party" and making frequent inquiries about her sexual fantasies about him. Later, he suggests that they have sex, claiming that this will remove her fear of men and cure her of being a lesbian. Initially she refuses, telling her therapist, "I feel I would be destroyed. In the end it would be bad for me."

The therapist insists that she needs to love him, so that she can learn to love men. Over the course of the next few months, he progresses from touching her, kissing her and caressing her. Over the three years that she saw her abusive therapist, when he returned from conference trips, he would bring her coins, records, trinkets, and other gifts. He also invited her to go to a conference with him.

♦ 7 Key Explotative Behaviors
Looking at boundary violations from the professional's perspective, Epstein and Simon developed an "exploitation index" for therapists. They describe the following exploitative behaviors:
1. Seeking a diversion from treatment: The therapist initiates social contact with patients.
2. Erotic: The therapist relishes romantic daydreams about patients.
3. Exhibitionistic: The therapist seeks out clientele who are famous or VIP.
4. Dependent: Talking about one's own difficulties.
5. Power seeking: Requesting personal favors from patients.
6. Greedy: Accepting large gifts.
7. Enabling: Failing to set limits because of apprehension about the patient's disappointment or anger.

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