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Report for the British Association for Counselling and Psychotherapy

Practitioners’ Experiences of Managing the Risk of Sexual Boundary Violations

Mary Godfrey, Institute of Health Sciences, University of Leeds Carol Martin, Institute of Health Sciences, University of Leeds Anna Madill, Institute of Psychological Sciences, University of Leeds Bonnie Meekums, School of Healthcare, University of Leeds

FINAL REPORT DECEMBER 2009

Acknowledgements
Our thanks go to the BACP for funding and supporting a study into this interesting and clinically significant area and to Sukdeep Khele (Suky), in particular, with whom we had much contact and who was helpful in so many ways. Also, we offer thanks to the staff in the Institute of Health Sciences (University of Leeds), especially Sarah Clarke and Sandra Holliday for financial and practical support, to Margaret Williams for her excellent transcriptions and to Julie Prudhoe for her administrative assistance. We are grateful to Anna Rossiter for conducting her systematic research review on a topic relevant to this research and for agreeing to her findings being incorporated into this report. We extend our thanks to Greg Nolan for conducting one of the research interviews and for engaging in the analysis of the data offered by this participant. We valued the positive response from the staff from journals who took our advertising and from the networks and organisations who distributed our information sheets. We are grateful to the group of expert clinicians who comprised our focus group, acted as advisors, and whose views shaped our approach to the data collection. We appreciate the feedback from our session chair, Nancy Rowland, and the audience at the October 2009 BACP workshop in Newcastle who reflected on an initial version of the findings. Finally, our thanks go to the participants who offered not only time, but who were generous in the extreme with their accounts of clinical activity, in their willingness to speak of their most difficult experiences and of their supervision. Each account made a unique and valued contribution

CONTENTS
Practitioners’ Experiences of Managing the Risk of Sexual Boundary Violations

Executive Summary Practitioners‟ Experiences of Managing the Risk of Sexual Boundary Violations ........ Chapter 1: Introduction and Literature Review ............................................................................. Chapter 2: Method ....................................................................................................................... Chapter 3: Participants‟ Characteristics, Motivation for Participation and Attitudes to Boundary Issues ....................................................................................................................... Chapter 4: The Therapy Work: Managing Risk ........................................................................... Chapter 5: Problematic Strategies and Creating Safe Boundaries

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Chapter 6: Supervision ................................................................................................................ Chapter 7: Summary, Conclusions and Practice Implications ...................................................... Appendix 1: Systematic Review ..................................................................................................... Appendix 2: Research into practitioners‟ experiences of successfully managing the risk of sexual boundary violations with clients .................................................................................. Appendix 3: Consent form .............................................................................................................. Appendix 4: Flyer ........................................................................................................................ Appendix 5: Interview topic guide ................................................................................................... Appendix 6: Ethics Approval Letter ................................................................................................ Appendix 7: Transcription Conventions .......................................................................................... References ................................................................................................................

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often using survey methodology. Brown and Stone. Brown and Stone (2007) conclude that provision of information is insufficient. evidence for the effect of recent innovations in training is promising. being male. however. The prevalence literature is primarily quantitative. Conversely an increasing literature exploring client experience of SBV suggests that the effects are profound (Ben-Ari and Somer. Research Aims and Questions The aims of the current research were to i . other reasons are more likely to play a part in sexual boundary violations. Somer and Nachmanil. 2005). Some studies identified general characteristics associated with SBVs. 2004. response rates. 2007). there are issues raised. for example. that UK accredited practitioners are ignorant of the code of ethics to which they have signed up. when considering recruitment and sample characteristics. Halter. including middle age. but evaluation of these is necessarily limited. and questions and definitions used. working alone and outside the public sector. It is unlikely. has been critical of the notion of the „bad apple‟. there is also a small but significant component of complaints. The evidence on sexual boundary violations (SBVs) in psychological therapy is sparse. Conclusions have limited accuracy. more recent literature. however.Executive Summary Practitioners’ Experiences of Managing the Risk of Sexual Boundary Violations Background Research evidence on unprofessional relationships across the caring professions considers a range of activities and definitions (Halter. but suggests that SBVs are under-reported.

or been subject to an investigation concerning. four participants were identified through personal and professional contacts. Data were analysed thematically (Miles and Huberman. participation was invited through advertising and electronic distribution lists. Inclusion criteria were: accreditation as a counsellor or psychotherapist within specified counselling or psychotherapy organisations. a preparedness to confirm that he or she had not committed. 2000). The sample therefore included individuals from both higher and lower risk categories. (2) Explore how practitioners manage these in their therapy work and the effects of such management strategies. 1994. choices and strategies adopted by practitioners. The sample was completed through purposive sampling. therapy models. working environments. The focus was on gaining detailed accounts of boundary breaches and potential SBVs. cultural background.(1) Identify the indicators that signal potential or actual sexual boundary violations by healthcare providers who are relevant to the remit of the British Association for Counselling and Psychotherapy.or homo-sexual orientation. experience and time since qualified. a sexual boundary violation. on reactions. Methodology Thirteen practitioners were interviewed about their experiences of managing the risk of sexual boundary violations. Braun & Clarke. some of this being outside the NHS. registering body and geographical location. age. Semi-structured interviews were used to elicit therapist experiences. each ii . disclosed hetero. to ensure that the sample varied sufficiently in terms of sex. To maximise the potential variety in participants and accounts. and opinions and judgements. (3) Make detailed recommendations to minimise risk of sexual boundary violations by such healthcare providers. extensive experience of clinical work since qualifying.

Elements of the steps involved in the therapeutic management of boundaries were developed into a process model created through analysis of what seemed to work positively for therapists and clients. with similarities to Celenza‟s (1995) definition of empathy. using the interviewer‟s experience to understand the complexities of the constructed account. The model articulates the following process: (1) noting. (6) working for therapeutic benefit. including sexual boundaries. whether the practitioner was acting in their own interests rather than for the client‟s benefit. and occurred without reference to sex of therapist and client. many accounts focussed on recognition and management of small breaches. The key factor identified in definitions of boundary breaches concerned motive. (2) facing up to it personally. Principles of Free Association Narrative (Hollway and Jefferson. (5) formulating. Experiences of sexual attraction originating from client and therapist were seen as ubiquitous and unavoidable.interview analysed initially by pairs consisting of an academic and a clinician.e. (3) reflecting. were integral to therapeutic work. Practitioners described a tension between engagement and sense making. (4) processing. therapists viewed the process as an ongoing struggle. we came to view this as a participant/observer stance. Findings Participants described SBV as one extreme on a continuum of boundary breaches. especially in views on touch. or sexual orientation. boundaries and their management. This model represents an ideal. 2000) were employed when extending the analysis beyond the participant‟s opinions and explicit themes. Definitions of breaches and boundary violations varied. by participant or research iii . the management of the experience was seen as critical in determining whether a serious breach had taken place. even though they were not descriptions of sexual boundary violations. For some. Some accounts of managing boundaries were deemed problematic. i.

Conclusions and recommendations These findings are not inconsistent with the literature and research on sexual boundary violation. manage the supervisory relationship. the strategies adopted for managing pressure on therapeutic boundaries sometimes resulted in distress to clients and difficulties with therapeutic work. and training organisations. Recommendations for practice have been framed as issues for reflection for practitioners. even though participants had avoided sexual boundary violations and had experience of successfully managing boundary threats. training in boundary management. and over-protective anxiety. so that threats of boundary breaches could be discussed. This extended for some to a responsibility to report serious unprofessional misconduct. Additionally. facilitate understanding. employing organisations. These include: increasing clarity over reporting. neediness/ over-identification. supervisors. Supervision was seen as the primary source of support for successfully managing boundaries. supervisor contracting. monitoring the therapist‟s account and their own experience. we focussed on experiences of supervision and views of its functions. moralising/ omnipotent. 1985). These were grouped into a typology of four categories: self-protective/ defensive. The sample tended to favour more conservative stances towards boundary limits such as touch. victims and transgressors. supervisors were expected to provide quality checks.team. formulation of practitioner learning iv . so that supervisors might support therapist work at any point. accrediting bodies. support during investigation. for example. Supervisors were expected to focus on client benefit. One of the major aims of supervision seemed to be the development of an internal supervisor (Casement. and an ethical and therapeutic stance. this may have been a protective factor. These mirror the practitioner‟s roles. A feature of all examples was a difficulty in maintaining a constructive balance between participation and observation. speaking of difficulties.

There are finally suggestions for future research. for practitioners to develop and own a rationale for therapeutic boundaries and prohibitions.needs. v .

2000). this boundary has been in place since the earliest days of psychotherapeutic work. There are several types of concern. 1993). all British accrediting bodies for psychological therapists incorporate principles and directions about the appropriate limits on relationships with clients. Furthermore. These include a prohibition on sexual relationships.. and perhaps derives directly from the values expressed in the Hippocratic Oath. often not only with current clients.Chapter 1 Introduction and Literature Review Introduction Recent government initiatives. that practitioners must make a commitment to avoiding harm to the client. many studies show how damaging sexual boundary violations can be in the therapeutic relationship for both client and practitioner (Hartl et al. 2007. Historically. indicate increasing public anxiety about professional relationships in health settings. A small literature describes the personal impact of breaches of trust on the client (Alexander. France. Currently. 1998. 2003.. demonstrated by the Alder Hey and Shipman cases. 1995. including the avoidance of sexual exploitation. One area for disquiet is the awareness of the potential for breaches of accepted boundaries through the development of sexual relationships between practitioners and their clients or patients. to cite two very well publicised examples.. This stance is 1 . including regulation requirements. Moggi et al. but also with past clients. It also warns practitioners to exercise considerable caution before entering personal or business relationships with former clients. Ward. In its Ethical Framework (2007). Norris et al. It further emphasises within the section „Keeping trust‟ that a client‟s trust must not be abused to gain sexual advantage and that sexual relations with clients are prohibited. the BACP states within „Ethical principles of counselling and psychotherapy‟.

and the factors associated with 2 . There is some debate as to what constitutes a sexual boundary violation. as part of the process of overcoming difficulties (Stiles. Research literature The CHRE Review is the most comprehensive and up to date compilation and assessment of the evidence relating to sexual boundary violations. however. 1990). and specifically that they must not have sexual intimacies with current clients. Brown & Stone. it is noteworthy that. They go on to state that “Clinical and therapeutic interventions inevitably render individual patients and clients vulnerable. 11). p. „Ethical principles of psychologists and code of conduct‟ (2002). We return to the issue of defining sexual boundary violations later in the report. The definition used by the Council for Healthcare Regulatory Excellence (CHRE) report reads “sexual boundary violations occur wherever a clinical or therapeutic relationship is turned into a sexual or sexualised encounter” (Halter. 2007. 5). 2007. by so doing. covering empirical literature between 1973 and 2006. In particular. the client may become vulnerable or open to potential abuse. the American Psychological Association (APA) document. given the amount of research conducted in the USA. states that psychologists should not enter into exploitative relationships. This fits with the aim of making it possible for clients to allow themselves to express or experience problematic feelings.. p. or former clients for at least two years after therapy.common across accrediting organisations. and trust relies on providing a safe and boundaried space in which these can be carried out without compromising the person‟s dignity and bodily integrity…It is always the responsibility of the practitioner to manage and maintain these boundaries” (Halter et al. Llewellyn & Firth. Elliott. It examines reported prevalence and incidence. Clear boundaries are identified as vital within the therapeutic relationship to help create a safe environment and build a trusting therapeutic relationship. the impact of sexual boundary violations on clients.

is based on a range of sources. studies carried out in the 1970s and 1980s offer rates of around 7-10%. prevalence rates are considerably lower and have reduced over time. Prevalence of sexual boundary violations From the Halter et al review. Prevalence.sexual boundary violations (characteristics of professionals. we find that prevalence rates reported vary with the information sources and the questions posed. More typically. Its remit is considerably broader than our particular focus in that it includes all health and social care workers and not just those engaged in counselling and psychotherapy. Response rates vary between a quarter and a half of those surveyed and there is no consistency in the kinds of behaviours asked about. between a third and a half of professionals were reported as being involved in boundary breaches. Surveys of professionals asked to disclose whether clients have reported sexual involvement with a previous professional. Where professionals self-report their own sexual contacts with clients. Thus. of clients and situational factors). it is derived from self-reports by individuals through postal surveys targeted at different professional groups. the evidence is problematic. and analysis of complaints or disciplinary action via administrative data held by professional regulatory bodies. As acknowledged in the review. On this measure. with some groups such as psychiatrists and psychologists being subject of more research interest than others. The highest prevalence rates derive from studies of professionals‟ acquaintance with colleagues reported to have engaged in sexual boundary violations. Studies cited are mainly US based but also include research carried out in Australia. indicate that around a quarter of clients relate such experiences. Europe and the UK. Other sources of prevalence data include: reports from professionals of their knowledge of colleagues‟ sexual involvement with clients. It is possible. for example. 3 . however that respondents within individual studies may be referring to the same cases. sexual contact with professionals reported by clients.

Whilst survey and questionnaire methodologies aim for representivity. It is clear also. 2007). It is not clear whether the decline in reports of boundary breaches reflects a real reduction or greater awareness of. prevalence of sexual boundary violations is difficult to gauge and research efforts in this regard face a number of distorting factors. a similar prevalence pattern to this international picture was found in the first national survey to be conducted – focusing on clinical psychologists who were members of the British Psychological Society (BSP). although only just over half of these had been reported (Garrett. guidelines and sanctions (Halter et al. associated with vying stakes and interests. Within the UK. The existing research literature already suggests that sexual boundary violations with clients by healthcare professionals form a significant component of complaints to regulating bodies. Even so it was not always clear whether different studies referred only to relationships with current clients or included those where the relationship occurred after termination of professional involvement. With over half (58%) of those surveyed responding. or because there may be fears of or actual professional and legal consequences. and perhaps anxiety over. Gabbard. Symon & Wheeler. In summary. 1998). and more recent studies reporting around half the prevalence. this largely depends on response rates and many of the studies report very low rates. can make it extremely difficult to know with certainty what really happened. such as the BACP (Khele. 22% of therapists had treated patients who reported they had been sexually involved with a previous therapist and 38% knew of therapists they suspected of sexual relationships with clients. that prevalence rates vary depending on whose perspective is being sought: the possibility of different perspectives on events. 4% admitted sexual involvement with a client. 1997). experiential 4 . 2008. People may be reluctant to participate either because responding may invoke traumatic or conflicting feelings. Structured methods moreover limit the kind of data collected.with those for men being two to three times the rate for women.

components are minimal. Inclusion criteria were: empirical studies. She was supervised by Anna Madill. What we can say is that sexual boundary violations comprise a significant problem to be addressed and managed – although the size of the problem varies depending on who is making the assessment. psychotherapists. 5 . although boundary breaches also involve homosexual relationships.e. Four main databases relevant to the issues were searched (PSYCINFO. A number of studies reported in the Halter et al (2007) review sought to identify personality characteristics that might distinguish those engaged in sexual boundary breaches. We thank her for her contribution to this report. The gendered nature of the problem has emerged from survey data: male therapists are reported as more likely to be perpetrators and women to be victims. the social processes that contribute to sexual boundary violations. and the contexts in which they occur. i. psychotherapists and clinical psychologists) in their work with clients?‟1 It was thus a more specific research question with its focus only on therapy professionals. victims and situational factors The difficulties in assessing prevalence are carried through into identifying the characteristics of those who engage in boundary breaches. the complexity of the individual case is lost. counsellors. are not elucidated. and clinical 1 This review was conducted by Anna Rossiter as part of her course work for a Masters in Psychological Approaches to Health. Medline and Social Care Online) over the period 1997–2008. Web of Science. Characteristics of perpetrators. This addressed the following question: „What are the indicators that lead to sexual boundary violations by therapy practitioners (counsellors. relating to psychological therapists. with little success in finding characteristics that explain much of the variance (Epstein. Simon and Kay 1992) We sought to explore this further by extending the literature covered by the CHRE report by a systematic research review of recent publications.

Celenza (1998) presents preliminary findings on the characteristics and predisposing factors in 17 therapists engaging in sexual intimacies with patients. Of these. e. two focussed on the therapists. Other types of boundary violation. and one identified a combination of client and therapist characteristics alongside situational factors. all male transgressors involved heterosexual transgressions (one or more). suggesting that this comparison may be overstated on the basis of a few well-publicised cases.psychologists2. The authors concluded that their findings challenged the easy comparison with sociopath repeat offenders. Of 2 The review uses the terms ‘practitioners’ or ‘therapists’ when referring to these types of health professionals. four used a combination of qualitative and quantitative methods. and one only qualitative methods. suggesting that there is little or no recent research on this aspect of boundary violations. Only six papers were categorised as empirical. three were concerned with associations between sexual boundary violations (SBVs) and client characteristics. and sexual boundary violations (SBVs) occurring in practitioners‟ work with clients. and some disturbance. mostly attributed to situational factors. Overall. Of the six papers.g. transgressions between supervisor and supervisee were not considered. scores indicated that the mental health professionals were not grossly impaired but did show acute distress. The scores obtained were compared to 700 non-patient adults. 6 . 14 men and three women. The search strategy. and women offenders transgressed in one homosexual relationship. who had engaged in sexualised dual relationships. papers identified and key findings are set out in Appendix 1. all of the empirical papers located were included in the Halter et al. With one exception (Moggi et al 2000). Additionally we sought out reflective literature that might throw light on the question. Celenza and Hilsenroth (1997) using Rorschach projective technique examined the psychological characteristics of 20 mental health professionals. one used only quantitative methods. review.

one woman sought treatment during her involvement with a patient. two requested supervision following suspension of their licence. Secrets in the family were commonly described. Celenza developed formulations based on the data. psychological tests. colleagues and. The power relationships in therapy were subverted as the therapist offered self-disclosures. and required the client to respond positively. What seemed most difficult for these therapists was to tolerate the client‟s view that the therapist was depriving them. clients. Therapists described poor early relationships. and restricted use of fantasy. She noted a theme of damage or wounding. intolerance of feelings of rage and aggression. In other words. what was impossible to tolerate was the client‟s disappointment and hostility when discovering that therapy and the therapist cannot. two sought treatment. these therapists fall into the trap of thinking that they can offer a corrective therapeutic experience and avoid aggression.these. five referred themselves and seven were referred by a professional association. two were involved in a patient initiated consultation. consultations with supervisors. while those who did not reported conflicts with authority and disclaimed responsibility. where possible. this offered a parallel for the transgression. Data were derived from comprehensive clinical evaluations. These therapists felt they could provide something that would make up for and obviate past and current deprivations. Of the remaining ten. 7 . many of these were affirmed by the therapists. Celenza uses Winnicott‟s model of optimal deprivation to demonstrate her understanding of this important therapeutic role. She concluded that it was impossible on the basis of these findings to predict therapist sexual misconduct or that the predisposing factors are characteristic of therapists who engage in sexual misconduct as opposed to those that do not. Those who felt remorse found it difficult to accept their feelings of anger. these therapists could not accept that their transgressions were hostile. leaving them with low selfesteem and feelings of neediness and damage or vulnerability. interviews.

No significant differences were found between groups for most risk factors. Ben-Ari and Somer (2004) investigated the aftermath for women who had engaged in TCS but whose relationship with the therapist had ended two years earlier. male. Questionnaire methods assessed risk factors within personality (self esteem. child molestation) and circumstances at time of psychotherapy (substance abuse. social functioning). often initiated by therapist self-disclosure and seductive behaviour. psychologist. female. lone working in independent practice) were described. love for therapist). Participants were recruited via advertisement. Eightytwo per cent of clients described TCS as a romantic affair. with a control group of 26 women. 8 . In another qualitative interview study. and therapist (reputable. neuroticism. main stream. personal background (neurotic style of upbringing. relationship and process. (2000) compared female patients (n=57) abused by their psychotherapists to female patient controls (n=43). Moggi et al. In a quantitative study. 70% also reported confusion and disorientation. history of child sexual abuse). However. marriage satisfaction. it was noted that this profile fits many therapists and is insufficiently sensitive to distinguish violators from others. However. Risk factors within client (younger. family atmosphere. Qualitative analysis revealed a gradual process of boundary violations. Sexual involvement with the therapist was not predictive of reports of mental health at the time of the survey.Somer and Saadon (1999) used questionnaires and a clinical interview to compare results from 27 women involved in therapist-client sex (TCS). middle-aged. The authors concluded that client factors did not predict sexual involvement with therapists and suggested that the focus of future research shift to therapist. but the index group identified more rejection and disapproval from parents and more long-term abusive sexual relationships in adulthood than the control group. Child sexual abuse was common in both index and comparison groups and did not seem to predict sexual involvement with the therapist.

although some still harboured positive or longing feelings for the therapist. Participants described poor past and parental relationships prior to the TCS. The TCS itself was seen as abusive and harmful. 9 . and low self-esteem. the authors describe a sense of transformation within the sample related to a more positive sense of self. Overall. relationships and their lives in relation to sexual involvement with their therapist. 14 agreed to be interviewed. and reported feeling stronger. and dissociation. focussing on personal characteristics and interpersonal relationships. Both groups reported dependency on the therapist. participants thought that therapists focused more on their own needs.Of 24 that responded. confusion. and after TCS) than those who construed the relationship as abuse. Deciding to participate in the study and resolving the decision to make a complaint or not were significant features of the accounts. during. whereas in the „romance‟ group. possibly as they reattributed responsibility for the TCS and previous unsatisfactory relationships. Many had returned to therapy. Open-ended questions were used to explore past experiences. Somer and Nachmanil (2005) interviewed 24 participants who reported actual sexual contact with their psychotherapist an average eight years previously. using questionnaires and narratives. emotional wellbeing deteriorated later. In the „abuse‟ group. after sexual contact ended: all felt exploited and betrayed by the therapist. Two constructs of the relationship were identified: „romantic‟ or „abusive‟. Research questions were concerned with the participants‟ views on experiences of self. visible in accounts offered in the previous study (Somer and Saadon 1999). Questions aimed to identify why these clients may have become involved in TCS. and present experiences of current self perceptions and views on relationships. Women were aged between 23 and 50 years and with one exception the TCS therapists were men. often with a female therapist. The group holding to the romance construct had better emotional well-being at all time points (before.

Gabbard 1997. Celenza and Gabbard (2003). of whom 327 responded (33% response rate). Although. Gabbard 10 . they appear to have very serious consequences for the client. these literature reviews support the accepted view that when SBVs occur. In a review of a number of disciplinary cases with which he had been involved. for the majority this is not the case – a conclusion drawn by therapists based on clinical experience of working with those who violate sexual boundaries (Foehl 2005. Woodburn and Buchko (1994). some studies have demonstrated common features of offending practitioners. Based on a survey of 1000 US psychologists. while sexual boundary violations happen only in the minority of cases.5% reported being involved in sexual relationships after termination of therapy – the majority of them indicating it was only the once (70%). and the remaining 10% five times or more. This suggests that whilst the „serial‟ offender represents a proportion of those engaged in sexual relationships. a further fifth on two occasions. analysts and counsellors (GG) who engaged in sexual misconduct. they found that 6. Norris. Celenza and Gabbard 2003. While client vulnerability is associated with higher prevalence.In summary. concluded that only around a quarter could be characterised as psychopathic. the practitioner. and the reputation of the profession. Gutheil and Strasburger 2003. Strand. supervision and evaluation of 48 therapists or analysts (AC) and 150 therapists. ‘Serial offender’ or ‘troubled’ clinician One issue of interest to professional organisations and regulatory agencies is the nature of the boundary transgression – specifically whether transgressions are carried out by a „predatory‟ professional or a „troubled‟ clinician. One study that sought to address this was carried out by Lamb. it is also concluded that these are not sufficiently distinctive as to easily identify potential offenders from others. Keith-Spiegel and Tabachnick (1986). This is similar to the findings reported by Pope. based on respectively the treatment. this is not straightforward and it appears to be a combination of complex factors which lead to SBV.

1986). In other words. consider that boundary problems are universal concerns and that failure to recognise this can lead to a “damaging reluctance to fully examine this topic in every setting – didactic. and a suggestion that there is an increased prevalence of harm in therapist samples over the general population of clients (Buckley. He posited that. there was a potentially escalating series of boundary breaches. consultative and supervisory. let alone improvements. training.(1997) suggested that practitioners who violate boundaries may have been unaware of some part of their experience. the need to maintain positive feelings in the relationship with their clients may have served to avoid the experience of conflict or aggression. this knowledge alone is not always sufficient to withstand the experience of anxiety or dissonance. There is also a possibility that some experience of personal therapy has been found by therapists to be harmful (Grunebaum. Karasu & Charles. Some training organisations. Equally. Through personal development and increased self-knowledge. The evidence for changes. whatever the practitioner knows about the existence of boundaries and their value. do require personal therapy with the intention of facilitating personal insight. or towards the client. remains ambiguous (Macran & Shapiro. One implication to be drawn from Gabbard (1997) is that an experience of personal therapy or counselling might act as a protective factor. 1998). and of the motivations that led them into the sexual boundary violation. in particular psychoanalytic institutes. that in an attempt to maintain these positive feelings. the practitioner may be better equipped to reflect on and develop ways of managing themselves constructively in the face of anxiety. It is possible to surmise from this paper and from other accounts (Celenza 1995). however. 1981). either from. there is a debate over the effects 11 . for some clinicians.” This point is reinforced by the findings of Pope et al (1986) that most therapists in their study indicated they had experienced feelings of sexual attraction toward at least one client. to practitioner behaviour from personal therapy. pressure or distress. Similarly Norris et al (2003:522).

(2007) cite findings that suggest that there is a range of opinions expressed by some samples of trainees and students in particular. a phenomenon considered by Gabbard and Peltz (2001). so that many practitioners qualify without the experience of being a client. 1999. 2002. and the potential for beneficial effects of training on ethical issues and boundary management. many practitioners. where. It is also worth noting that Halter et al. Anecdotally at least. There is some evidence for the positive effect of more active educational strategies. As it is. However. especially those who have been qualified for some time. as in clinical practice. one variant of which is named „the analytic virus‟. there is currently relatively little support in the UK for the requirement for personal therapy to be extended. it may be some time before it is possible to evaluate any long term benefits of such strategies.on practitioners of experiencing distorted or exploitative professional relationships with trainers and supervisors. highlighting the areas of confusion among therapists and students. there has been a recent emphasis on personal development as an alternative to therapy. and to develop and practise strategies for responding therapeutically to situations in which there is a threat to boundaries. The focus on providing such opportunities in training has been relatively recent. that would be in conflict with the ethical codes of some regulating 12 . These include the provision of opportunities for practitioners to discuss these issues openly in a non-judgemental setting. Discussing the impact of attraction to a client may aid the successful management of sexual boundary issues (Halter et al. Hughes & Youngson. 2007). 2008). Further. there is also a power differential. with the aim that practitioners might better understand themselves and their experience (Macaskill. one of the factors considered significant for unprofessional behaviour in practitioners seems to be the experience of feeling betrayed by one of their trainers. and some pressure against extending it. Johns. may not have experienced such training and again Halter et al (2007) have evaluated this literature.

It is unlikely that ignorance is therefore a major factor when practitioners become involved in sexual boundary violations. Since the development of plans for making accreditation a requirement. the most typical pattern is of the troubled clinician who slides down the slippery slope. it is extremely unlikely that trained practitioners will be entirely unaware of the ethical code to which they must adhere in their practice. if not all. therefore. cited in Halter et al. therapy and counselling training courses include at least some teaching on ethical conduct. opinions were more mixed when considering such relationships with former patients (Coverdale & Turbott. 1997. in one study on medical students it was reported that. it might indicate a need to review accepted limits. practitioners have been required to sign up to codes of ethics.organisations. and most send paper copies of such documentation both on first date of accreditation and when these documents are amended. however. and remediation. earlier experiences of abuse. while having sex with a current patient is not considered acceptable. it suggests the need for clearer and more effective training. 2007). and possible deviations from the accepted conventions. Such differences. and it is necessary. including professional isolation. Given that many. Moreover. conduct and practice. More radically. offer potential for developing strategies and approaches that might offer success through influencing training. the albeit limited evidence that most therapists experience sexual attraction to a client at some point – even if they do no 13 . Accrediting organizations ensure the availability of these. In summary. and personal distress. At the least. practice. whilst there is some evidence that a number of vulnerability factors implicated in sexual boundary breaches. are of concern. This means that the task of predicting and preventing SBVs may be more complex than previously envisaged. to look for other explanations. For example. developing an inappropriate relationship over time. It does.

Our study The aims and objectives of the current research were defined as follows: 1. psychotherapists and clinical psychologists in their work with clients? 2.act on it – suggests scope for exploring the kinds of strategies employed to manage risk of boundary breaches. To make detailed recommendations to minimise risk of sexual boundary violations by such healthcare providers. We translated these aims into the following research questions: 1. How do practitioners manage these in their therapy work and what are the effects of such management? 14 . To identify the indicators that lead to sexual boundary violations by healthcare providers who are relevant to the remit of the British Association for Counselling and Psychotherapy. 2. What do practitioner accounts tell us about the indicators that signal potential or actual sexual boundary violations by counsellors.

The development of the methodology is also described along with the procedures followed during the study. the study was designed to elicit accounts of events that might be seen as precursors of boundary violations in clinicians‟ therapy work. and in recounting the event. Context and research focus This research was designed with the understanding that an accredited practitioner at risk of committing a sexual boundary breach in the United Kingdom will be aware of the ethical dimensions of their feelings and behaviour. shame and punishment. It is. The team considered several possible strategies. These may include fears of exposure. about deciding to access support. It is likely that in these circumstances. The period of contemplating or initiating the first steps of a sexual boundary violation is likely to arouse anxiety. however. and will attempt to reach a satisfactory resolution of the internal pressures experienced. or at least disquiet. he or she may experience conflict over the event itself. The focus for the study evolved. b) were able to give accounts of therapy work where the strength of feelings of attraction to client(s) resulted in the 15 . These were interviewing a sample of practitioners who (a) were prepared to talk about actual sexual boundary violations. through the understanding of these experiences that it may be possible to draw out guidelines for practitioners who face such events. With this in mind.Chapter 2 Method This chapter outlines the evolving aims of the research as the team responded to the requirement to recruit a sample of participants who would provide „information rich‟ data to answer the research questions.

or c) had expertise in the successful management of sexual attraction in therapeutic work. accounts from those who had experienced an investigation may be shaped by the process and outcome. Recruitment of an expert sample also posed difficulties. recruiting participants to talk about „near misses‟ raised ethical issues for those whose description of a near miss constituted an actual boundary violation for the interviewer and team. The first was discarded because it was anticipated that there would be ethical issues over recruitment. and would not be representative of practitioners‟ successful management. given the range of possible definitions of SBV. these individuals would need to identify themselves in this way. 16 . who might avoid coming forward. whether avoided through chance or deliberate action. and it would be unethical given that the clinicians involved with the study adhered to Codes of Ethics which require reporting of colleagues‟ professional misconduct. the final design involved us seeking a typical a sample as possible. furthermore.experience of a „near miss‟3. including individuals who represented risky and protective demographics. the additional expertise might reduce the sense of uncertainty and lead to accounts that were less typical of the process experienced by those who felt anxious about the possibility of boundary breaches. Similarly. In addition. such as an accident or injury (in this case a SBV) but did not. 3 A near miss is defined as an event or situation that could have resulted in undesirable consequences. Also. finding participants who had not been apprehended would be difficult. we suspected that using this rationale for recruitment might increase the anxieties of potential participants. focus on the strategies therapists employed in their day to day practice to manage experiences of sexual attraction. This strategy was also informed by our reading of the literature: if sexual boundary violations need to be considered as “more than the province of a few that have nothing in common with the rest of us” (Gabbard 1995:1116). would offer a way of examining therapists‟ vulnerabilities in the therapeutic environment. For these reasons.

Qualitative methods allow an analysis that captures complexity and nuances of participants‟ experience and the meaning they place on events as they give their accounts. 17 . Moreover. A qualitative research approach would: (1) Provide accounts of practitioners‟ views and beliefs in relation to vulnerability to breaching sexual boundaries. seemed inappropriate for the research aims and would have required lengthy and impractical qualitative components to collect data that would have been of sufficient value to offer guidance to the profession.Choice of research methods Quantitative methods. (4) Encourage detailed discussion of the practitioner‟s definitions. even questionnaires. there has been increasing interest in using qualitative methods in counselling and clinical settings. there were several advantages to adopting a qualitative research strategy for this study‟s focus on practitioners‟ experiences of managing the risk of sexual boundary violations. including the use of external and internal supports and resources. in depth qualitative research findings may extend understanding of other research studies and provide useful support for practical recommendations. values and strategies for management of events involving sexual attraction. (2) Allow practitioners to offer a complex narrative enabling an analysis of the key moments of conflict and choice. Hence. (3) Allow researchers to use their reaction to the participants and to their stories to inform a deeper human understanding of their struggles. Although it is not possible to generalise extensively from a small sample. The frameworks and principles arising from such studies may guide understanding and identify future areas for exploration. and the management of potential sexual boundary violations.

Three have experience of ethics committees for either clinical or research issues. in which a sample of practitioners were interviewed and asked to provide accounts of their views on sexual boundaries and their experience of negotiating these with sufficient success that the practitioner managed to avoid sexual boundary violations. In this study in particular. process. the way in which the data is understood by the researchers requires explanation. in particular. disciplines. The team recognised that these might include fears of being seen as 18 . Two have clinical components to their posts and are accredited as practitioners. In particular. All have experience with qualitative research methods. the researchers were aware of the potential for accounts to be shaped by the anxieties of the participants and. while they added depth and relevance to the analysis of clinical material. and therapists‟ experience. As in all qualitative research. The composition of the team brought several advantages. All team members also have an interest and previous involvement in research into the practice. and outcomes of counselling and therapy. the combination of clinical and academic members allowed some confidence that the clinicians were not limiting the analysis through their assumptions about the nature of clinical work. all female academics from different. anxieties about the judgements of others.It might have been possible to offer answers to these questions through a number of study designs. This is perhaps especially necessary when the data is participant narrative rather than direct observation and the content of the interview is likely to be emotionally complex and anxiety-laden. with a variety of positions and research strategies. Reflexivity: Reviewing the research team’s understanding The research team consisted of four core members. The eventual decision was to use a qualitative design. the clinicians themselves worked with different frameworks which made it possible to avoid the uncritical adoption of one model of psychological work. albeit related.

Martin. First. could lead to a change in the practitioners‟ expressed views due to the need for self-protection. participants might feel a wish to elicit reassurance or recognition. Moreover. it was decided not to interview practitioners who had broken a sexual boundary in the course of their work (with clients. or even to be considered as having acted in a way that merited reporting and investigation. the discussion of actual transgressions poses ethical challenges beyond the scope of this research.incompetent. we were aware that the consequences of breaching a sexual boundary. clinical psychologists) who identified themselves as having experience of sexual attraction between client and practitioner. and of any subsequent investigation. students. (2) Analyse these interviews using a thematic qualitative methodology in order to explore: 19 . the specific objectives that evolved were to: (1) Recruit and interview 12-15 relevant healthcare providers (counsellors. 2001). or imagined readers of the research report. might stand in for judgemental others. psychotherapists. inarticulacy. concern over being perceived as acting inappropriately. in order to fulfil our research aims and research questions. 1999. We were also aware that the interviewer. Such concerns would be likely to lead to inconsistencies. or supervisees etc. or even the possibility that participants might experience interviewers as external versions of internal critics (Hollway & Jefferson. Given the above consideration. and of having managed this in ways that did not result in a sexual boundary violation with a client. The methods of data collection and analysis needed to be able to take these into account. 2000. The reasons for this were twofold. or moments of tension in the accounts. including registering bodies and condemning colleagues. Additionally. Second. Kvale.).

(a) Practitioner definitions and characteristics of appropriate maintenance of boundaries. to maximise the depth and sensitivity of our study through incorporating researcher reflexivity throughout the processes of data collection and analysis. the factors giving rise to the temptation to commit a sexual boundary violation and how such temptations are managed successfully. 20 . (c) Views on reporting violations and near misses. With the development of qualitative approaches that can recognise the ways in which an account may be shaped. including the role of clinical supervision. through interviewer debrief meetings so that the researchers‟ reactions to talking with participants could be used to develop insight into the topic of practitioners‟ experiences of managing the risk of sexual boundary violations. there is potential for a clearer understanding of the experience of these dilemmas and problems and therefore for developing frameworks and recommendations. of their understanding of what would constitute a sexual boundary violation within the context of their work with clients. through detailed descriptions of practice examples. for example. (d) Reflection on. available guidance on managing sexual boundaries with clients and the use of this information. and attitudes to. and which include systematically the experience of the researcher in analysing the data. The methods developed for use in this research aimed. (b) Views on whose responsibility it is to maintain boundaries. therefore. (e) Knowledge of. and. (f) Experiences of training aimed at promoting ethical practice. This was operationalised.

It was agreed that no participant would be interviewed by an interviewer with whom there was a previous or current relationship and that.Ethical issues A number of ethical issues were discussed in relation to this study. especially where there might be differing views on what constituted a boundary violation between therapy modalities. the potential for previous or on-going professional or social relationships between some interviewers and some interviewees. where such a relationship existed. the use of accredited clinicians as interviewers potentially placed both researcher and participant in difficult ethical positions. As researchers. and the disclosure of previously unreported sexual boundary violations. we felt we had a duty of care to participants. Written materials were stored in locked filling cabinets. In particular. interview data was digitally recorded and deleted from the recorder after being stored on the main university server only (a secure. Solutions to the issues were adopted as follows: the study developed information sheets describing the study and consent forms (appendix 2&3).g. the data would not be analysed by that researcher. Transcribers signed a confidentiality agreement and were given guidance on conventions for anonymising transcripts. and identifying data were kept separate from interview transcripts and audio recordings. There is also a duty of care to clients and accredited clinicians agree to abide by Codes of Ethics and Practice that include statements to the effect that they will not condone and will 21 . anonymity of participants. e. Given the sensitivity of the topic there were concerns over the storage and disposal of data. Both auditory and textual data will be archived within LIHS for seven years as required by the University of Leeds and destroyed after that point. password protected site). I2 P3. Transcripts were titled with a code number for interviewer and participant.

University of Leeds (appendix 6). both in the written materials and during the interview. through the BPS and UKCP. the interviewer might be obliged to report it to the participant‟s professional organisation for investigation. The study was reviewed and supported by the Ethics Committee of the Leeds Institute of Health Sciences. as they would might be able to offer a rich and detailed account. Additionally. the participant would be given time to make the report themselves. the interviewer would warn the participant if (s)he became concerned that such a disclosure might be made.report potential misconduct4. Hence. The potential 4 Two of the four interviewers were accredited clinicians. if that was wished. there were no accounts within the data set amounting to misconduct of a degree of severity that the team considered the need to report any participant. and that if this was the case. at the start and at any point that the interviewer became concerned that the participant might be disclosing a previously unreported sexual boundary violation that the interviewer felt would be likely to require reporting. In order to protect potential participants. an important issue was the need not to invite confessions of misconduct. In the event. Sampling strategy Our sampling strategy was developed to reflect ethical and theoretical considerations. that if there were a sexual boundary violation described. If it were decided that the breach required reporting. 22 . it was agreed to make explicit statements. Our initial thoughts were to recruit practitioners who would define themselves as having experienced a „near miss‟ in relation to a sexual boundary violation with a client. the interviewer would inform the participant that (s)he would discuss the event with the research team and let the participant know the outcome. These were to the effect that the aim of the research study was not to collect accounts of actual sexual boundary violations and the interviewer would not seek accounts of these.

the British Psychological Society. the researchers could not assume a direct correlation between self-definition and expertise. more open about their experience. however. more or less constructive. to cope with their dilemmas. and would potentially have developed strategies.variation in practitioners‟ definitions of the difference between a „near miss‟ as opposed to a breach. the United Kingdom Council for Psychotherapy. without observations. have been exposed to the same struggles. particularly „information rich‟ for the proposed research. Our solution was to draw our sample from experienced and practising practitioners that were currently accredited with one or more of the following organisations: the British Association of Counselling and Psychotherapy. again left the team aware of the conflict between the need to protect participants and the obligation to report misconduct. This meant also that the agreed focus for the interviews was on experience of. Asking practitioners to identify themselves as skilled and experienced in these areas. we considered that they would be more prepared to be interviewed. the British Psychoanalytic Council or the Association for Dance 23 . For this reason. There seemed to be no straightforward way to recruit participants who were expert at negotiating sexual boundary events in therapy. So. to similar circumstances. and less motivated to produce a deliberately distorted or selfprotective account given that they managed to avoid a breach of guidelines and of their code of ethics. In contrast to those who have actually violated a sexual boundary. Participants would. or expertise in. we were explicit that participants had to declare that they had not committed a sexual boundary violation. however. we recognised. potentially. would bring forward those with the confidence to self-define in this way but leave us unable to attract a range of practitioners who might be more tentative about their abilities. whether investigated or not. managing potential threats of sexual breaches to therapeutic boundaries. Practitioners who have experience of managing such events without becoming involved in a sexual boundary breach were thought to be.

Movement Psychotherapy UK5. This excluded those still in training or not currently accredited. This would increase the likelihood that the findings might resonate with the body of practitioners. for pragmatic reasons. multiple site R&D approval. we sought to include a mix of male and female participants within different age groups. and to increase the variation in the motivation for participation. Further. Two main strategies were employed. and honorary NHS contracts for non-NHS researchers. the sampling strategy was theoretically and purposively driven. These included an initial report and a notice in Therapy Today. Following a number of interviews. we decided not to recruit participants via the National Health Service (NHS) but to only recruit therapists via other routes and whose main clinical work was conducted outside the NHS. In summary. and emails distributed through local and national organisations and email 5 This was chosen in order to broaden our sample to include therapists practising outside of the verbal therapies in which the body is a central vehicle for the work. a secondary sampling approach was devised to ensure inclusion of participants of different sexual orientations. which would have meant a delay to the study deadlines. 24 . and second because there is a suggestion that independent practice may be a risk factor. in particular the time constraints on the study. given the potential impact of gender and age on vulnerability to sexual boundary violations. 6. First. a page on the University of Leeds website was developed with an email link. a notice in The Psychologist. the practical one of avoiding the need to secure NHS ethical approval. several methods were harnessed for disseminating information about the study and attracting potential participants. Recruitment We decided to recruit through several routes in order to maximise the potential for a range of participants and accounts. 6 This criterion was included for two reasons: first. Finally.

The source of recruitment and characteristics of the participants are outlined in Chapter 3. A revised version of the topic guide was developed and two pilot interviews were carried out with a volunteer who fitted the inclusion and exclusion criteria. two of the team (CM and BM) consulted a panel of clinicians with extensive experience of counselling. The focus group members commented on the proposal. Second. on interviewing and a draft of the topic guide. The participant was free to develop their own account in the way that made most sense to them while the interviewer followed-up unanticipated. Given the potential for anxiety arising from the interview focus. Given the sensitivity of the issues involved. and the possibility that some participants might feel more 25 . The interview schedule was developed in a number of stages. relevant directions of enquiry if introduced by the participant. to extend recruitment. to use the guide to map identified areas for exploration.networks. and the only criterion employed was that participants were assured an interviewer who was unknown to him or her. One pilot interview was included. so that the final sample comprised thirteen practitioners. Data collection Participants were interviewed using a semi-structured format. This group meeting was audio-recorded and a transcript made of the feedback from the panel members for use in developing the study. A focus group methodology was used for this. four participants were identified through personal and professional contacts. and to use consistent and recommended phrasings in questions and prompts. Participants were interviewed by any member of the team who was able to offer an interview. The interviewer‟s aim was to offer the initiative as far as was possible to the participant. therapy. An interview protocol was developed which interviewers used flexibly and as a guide to increase coverage of the main topic areas (appendix 5). and training.

and to ensure a clinical reading of each transcript. In two cases. 26 . and the interviewer took more extended notes7. Transcription conventions are included in appendix 7. Advertising material offered this option and one participant did request this. the participant asked for the interview to be recorded as co-constructed notes which were agreed after discussion at a second meeting.comfortable talking with a male interviewer. interviewers made notes of their experience. The interviewer attempted in both cases to make notes as close to verbatim as possible. the process by one of the team members. This allowed the interviewer to reflect on the experience in the presence of another. Each pair consisted of an academic and a clinician. so that a fifth interviewer was brought in to conduct the interview (GN). the digital recorder failed. but the methodology evolved in response to the challenges of the data. They then met another member of the team as soon as possible for a debriefing meeting. the recording of the debriefing meeting served as an opportunity to extend the record of the interview itself as well as to provide additional information on the interview experience. He was prepared for. and supported through. The transcripts were therefore worked on by two of the team. where there was no auditory record. which was digitally recorded and transcribed. Data analysis The analytic process was initially conceptualised as a focussed thematic analysis. we used Free Association Narrative 7 In one case. In the other. it was agreed that we would ensure that the analysis would take account of the interviewer‟s experience and make best use of the varied academic and clinical expertise of the team. Immediately after each interview. arrangements were made for this eventuality. Given the team‟s awareness of the sensitivity of the topic and the potential for emotionally-laden material and for anxiety. drawing on Miles and Huberman (1994) and Braun and Clarke (2000). To assist these steps. and initial reflections captured and refined through discussion. in order to challenge commonly held assumptions made by clinicians.

key processes. experiences. the pair met for development of the analysis and to reach consensus on the themes identified. including notes and records of the debriefing meetings were available for this phase. anxieties. Memos were constructed during this process. An initial thematic analysis was carried out by the interviewer and a second team member. Stage 2: Participant responses to the questions on attitudes and beliefs were identified. Following this. There were therefore a number of stages of data analysis. Stage 4: Accounts of clinical experiences of attraction were identified and themes arising from these examples were considered in relation to each other across the sample. Stage 1: Transcripts of the participant interviews were first checked by the interviewer.(FAN) principles as developed by Hollway and Jefferson (2000). and choice points were identified. outlined below. All of the data. From these. outlining issues arising from the discussion and commentaries on the development of the themes. changes of linguistic structure and topic. Stage 3: Each transcript was allocated to a second member of the team. These were incorporated into diagrammatic form reflecting the core process being described by participants. An analysis of problematic experiences led to the emergence of themes which were developed into a typology. to consider additional themes as well as to elaborate on and refine their dimensions during several meetings. and sequences of text as indicative of the complex processes involved in constructing the account. 27 . who corrected errors and added initial comments. A marked copy of the transcript was developed which identified the sources of the agreed themes. FAN draws on psychoanalytic theory in requiring the analyst to pay attention to the significance of possible reluctance. The debrief interviews were listened to and reflective memos developed.

some from the review conducted by Anna Rossiter. then reviewed and tabulated. analysis was conducted in stages with discussion at several points. Contextualising the findings: Secondary literature reviews During and after the analysis. a body of reflective literature (as opposed to empirical reports) provided a source of clinical experience and expertise which could be considered practice-based evidence.Stage 5: Accounts of experiences in supervision were collated and analysed separately. Again. A total of thirteen papers were identified and sourced. Themes were then identified from the reflective literature by two team members. In particular. who refined these into the form offered in the concluding chapter. Each transcript was checked by the interviewer against the original recording for accuracy. the team instituted several checks of the analytic process for a number of purposes. and accounts of events have been 28 . To this end. key themes were identified and a model developed describing the process through which supervisees worked as they used supervision to manage their experience with the client. Quality checks as part of the analytic process As can be seen in the above description of analytic procedures. Team meetings were used to discuss the analysis as it progressed and themes were shared across the team members so that developments from one pair influenced other analyses. the team members read all transcripts. unless this would breach an assurance of confidentiality. the team pursued further relevant literature. the prime considerations were to provide a flavour of the participants‟ views and experiences. Reporting conventions In offering data from the interviews. short verbatim extracts have been selected for inclusion.

Given the relatively small community of practitioners. 29 . some. several. unless the absence of such information is essential for making sense of the account. and the detail provided on their work practices. there is an indication of proportion.described. At other times. many and most. we reached the decision to include these without specifying from which interview each was taken. to age. Extracts have been amended to be grammatically correct and repetitions and hesitations removed unless their absence significantly changed the meaning of the extract. they are italicised. Extracts are either indented between paragraphs in the text or at times are included as part of the text. sexual orientation. References to gender of participants and others. it was decided that extracts and accounts would be kept brief and presented with the minimum of identifying contextual material. This reflects the team‟s preference for managing uncertainty. In both formats. there were topics that some participants did not raise or were left implicit in the accounts. the majority. or other characteristics have been avoided. Rather than assume that only those participants who explicitly discussed a theme held this to be important. At points. we have used terms such as a few. the exact number of participants offering a theme or having a particular characteristic is specified. working environment. Given the small sample. for example. and the order given is that intended to be taken by the reader.

The largest single group were seven counsellors. practitioner group. This balance was deemed to adequately cover the over-representation of male transgressors in studies concerned with identifying characteristics of offenders.1). In terms of profession. or were currently. four responded to emails sent out via local networks. Motivation for Participation and Attitudes to Boundary Issues This chapter outlines the characteristics of the participants in the sample. Although the majority of participants worked independently. The sample was sourced through several routes. It also means that accounts of the high risk „middle aged male‟ practitioner is represented within the data set. and some of those described as in public sector employment had previously worked independently. there were several who had been. including the NHS. The final participant was recruited for piloting the interview. potentially expert. Four contacted team members after having seen advertisements in professional journals. in public sector employment. Demographics The sample was made up of seven men and six women (table 3. all BACP accredited. Three identified 30 . and four were recruited directly because they increased the heterogeneity of the sample. several had more than one training or definition. The age range was weighted towards older participants. which has the advantage of allowing the collection of accounts from an experienced. indicates the motivations offered for agreeing to take part. including recruitment source.Chapter 3 Participants Characteristics. and explicates the views expressed during the interview.

31 . Two noted specifically that they offered counselling to adolescents. All thirteen had experienced regular supervision arrangements through most of their work as therapists. Two had group supervision. one as systemic. and one used cognitive-behavioural concepts. Eight of the participants spoke of experiences of personal therapy. one as relational. Three were clear about never having undertaken therapy for themselves.themselves as psychoanalysts or psychoanalytic psychotherapists. The two practitioners who were not in supervision at the time of interview were recently retired. Two participants also worked with couples. Three described themselves as integrative. two with families and three with groups. eight individual supervision (one or more supervisors) and two used peer group supervision (one practitioner had both a group and individual supervision). and all but two were currently in such an arrangement. Seven preferred psychoanalytic or psychodynamic models. Two were accredited as Dance Movement Psychotherapists. All thirteen offered individual therapy. and one counsellor also worked as a life coach. The thirteen identified the therapeutic approach they felt reflected their primary model. one of these was also one of the two clinical psychologists. and two did not speak of personal therapy at all.

Weekly None currently 3 weekly Weekly Monthly Dance Movement Individual. couple 1 Fortnightly Fortnightly 20+ 20+ 11 Weekly 2 different supervisors monthly Monthly BACP UKCP Counselling Counselling 32 . group Psychotherapy Dance Movement Individual. group Individual Individual 22 16 21+ 2 9 20+ Previously weekly none currently.Table 3. family Individual Peer group Individual Group Individual Individual Individual Individual. couple Individual. group Individual. adult Individual.1: Description of participants Identifier Sex Age (yrs) 50-59 Employment Registering Bodies BPS/UKCP Qualifications Therapy modalities Individual Supervision Type Length (yrs) Peer 5 Frequency Fortnightly I1 P1 F Public sector P2 P3 P4 I2 P1 P2 P3 I3 P1 P2 P3 I4 P1 P2 I5 P1 M F M F F M M M F M F M 60+ 50-59 60+ 30-39 40-49 60-69 50-59 40-49 30-39 60+ 50-59 40-49 Selfemployed Selfemployed Selfemployed Public sector Public sector Selfemployed Selfemployed Selfemployed Selfemployed Selfemployed Selfemployed Selfemployed BPS BCP BACP/AFT ADMP UK ADMP UK BACP BACP BACP BACP Clinical Psychology/ Psychotherapy Clinical Psychology Psychotherapy Counselling Individual. family Individual. group Psychotherapy Counselling Individual Counselling Counselling Counselling Psychotherapy Individual Individual Individual Individual.

by others. Some found that their engagement with certain client groups or areas of work raised sexual boundary issues frequently or strongly and. that they had offered themselves in the hope that their experiences would contribute to changes in training and professional activities so that future cohorts of practitioners would not have the same struggles. There were. 33 . felt they had developed expertise through experience. and felt that these issues had been inadequately explored during training. however. the desire to ensure that these issues might be better understood in the service of the client‟s development. Concerns were expressed about client well-being and.The participants expressed a variety of reasons for taking part in the study. Some were aware of having to learn to manage clinical situations where sexual boundaries became a cause for anxiety or concern. an interest in the role of sexuality in therapeutic work (six mentioned the importance for their work in particular. differing views toward „lesser‟ boundary crossings which were expressed in relation to a number of other types of breach. Practitioner views on boundaries and boundary keeping The unanimous view of participants was that for a practitioner to engage in a sexual relationship with a client is wrong. Several had found the presence and affective potency of sexually charged components of therapy challenging. Many had felt unsupported and there was a strong sense from several participants. or for therapy in general) and interest in ethical issues (three had been involved in the ethical processes of accrediting organisations). and even surprising. in less than ideal circumstances. and terms such as „intolerable‟ were used to describe this. The two most common reasons offered were. Touch was considered a breach by some practitioners while it was seen as a valid component of the work. which it might be helpful to share. A further theme can be best construed as altruism. at times at least. therefore. in particular.

” However. such as flirtation. even for apparently therapeutic reasons. Views varied on when and how self- 34 . For some.“I don‟t physically touch the client but I will habitually shake hands as part of normal human contact. there was concern over self-disclosure. One also described a decision to avoid touching clients after feeling intruded upon by the touch of a supervisor. one participant pointed out that physical touch was the mode of greeting in his culture of origin and that it was not given the same meaning among English friends and acquaintances. Other behaviours.” Of note is the fact that the two Dance and Movement therapists adopted strategies for managing and minimising touch: “I use a lot of work with props so there‟s sort of the more touching through props and …the sharing and exchanging of communication that way. one participant described an incident that led him to change his stance when he put his arm around a distressed client and felt her resistance: “There was a feeling then that it was a token of being the warm empathic counsellor to hold your client…. For example. was considered risky. Meeting outside the therapy setting. I barely used touch again because of that. were viewed as potential precursors to more substantial breaches.” “Never reach out and touch a client who is distressed – it‟s wrong to play on a client‟s vulnerability. both developed stronger prohibitions on touch or other non-verbal behaviours following experiences with clients who misinterpreted gestures. who had challenged his taken for granted behaviour both generally and in therapeutic encounters.” Two participants described a transition in their practice from one view to the other. and apparently minor breaches such as lapses in keeping to time.

These included accepting gifts. but the general principle underlying decisions was client benefit. Supervisors were the usual source of guidance. concerned over harm to clients. One participant also found the conduct of colleagues who initiated affairs with each other as problematic. or when there was a threat to a sexual boundary. and their advice was taken seriously. There was lack of clarity over the type of evidence needed to make a complaint about a colleague‟s conduct. Most were able to describe experiences of using supervision to discuss attraction to clients. seeing the client socially. with the anxieties that it might be considered gossip or malice. All participants recommended the use of supervision for understanding and managing threats to the boundaries of therapy. dating and initiating email contact. and self. Such situations placed participants in anxious and conflicted positions. there were concerns about potential conflicts between reporting misconduct and maintaining confidentially should a practitioner reveal breaching sexual boundaries in their personal therapy (the requirement to report being seen as meaning the loss of an opportunity for the practitioner to learn to work within accepted boundaries). developing the therapy into a friendship.disclosure was acceptable. even when this left the practitioner with a degree of unease. Those participants who discussed supervision experiences also considered that sexual relationships with supervisees were unacceptable. All participants also held the view that it is the practitioner‟s responsibility to maintain boundaries. Moreover. One issue raised by several participants was the uncertainty they felt over reporting their concerns about the conduct of colleagues and clients who were practitioners. This extended 35 . or for other types of clinical issue involving sexual feelings or material. Several participants noted that they viewed other specific behaviours in relation to clients as boundary breaches. Such discussions were not uniformly experienced as positive and this is discussed in more depth in Chapter 6. or even desirable. practitioner.

and not their own. One of the defining principles for most participants was that their actions should be carried out for the client‟s benefit. one of these thinking that while one could not avoid passing fantasies. Several participants categorised sexual fantasies about clients as a potential boundary breach. 36 .precisely because it would be easy to argue that it would do the client no harm. and then only some time after termination.” However. Eight participants made statements to the effect that sexuality was universal and was therefore a normal. “But its okay to have difficult feelings…you can‟t pretend that sexuality isn‟t part of therapy. and even usual or predictable. so that it could be used to the client‟s therapeutic benefit. and several commented on the difficulty in developing a more mutual relationship for both individuals. while yet another felt that it was a matter of the persistence and location (outside sessions) of fantasies which were indicative of a breach. and this arose at times when discussing fantasy. the deliberate use of such experiences for one‟s own satisfaction constituted an abuse.for many to the possibility of relationships with past clients. several participants considered that fantasy was a source of information and that the practitioner‟s task was to understand what it might mean for the therapeutic situation. perhaps . with some particularly concerned with the inequality in power between practitioner and client. Some felt that the need to overcome this power difference when developing a personal relationship would be problematic regardless of other considerations. sexual fantasy proved a problematic area for boundary breaches. Others questioned whether the differences intrinsic to the therapy relationship could ever be overcome. One participant was prepared to accept such fantasies and thought that they were harmless. component of the therapy experience.” “Sexuality is ubiquitous. one participant talked of dreams about clients in the same way. Only one participant thought that successful post-therapy intimate relationships might be a possibility. On the other hand.

denies them the chance to have therapy. “The wrong side is sexualising the relationship. A further theme was the recognition that sexual feelings may be understood as part of the difficulties the client brings because s/he struggles with this area of living. and others providing more empathic interpretations. without having to be taken through a punitive disciplinary process.There was also a theme of sexual boundary breaches and their management as forming continua.” 37 . “I will protect myself professionally even when it leaves the client feeling very distressed. and that practitioners need supervisors and colleagues to note these early breaches and work with them over these. Management of this varied. or avoidance of the issue: “…. with some responding to such issues by explicitly restating the boundaries they worked to.” “Feeling you want to push the client away because you cannot deal with it. It‟s appropriate to explore sexuality but not to sexualise the relationship. These included the recognition that the practitioner‟s anxiety might lead to a rejecting or punitive response.” Along with the Scylla of the sexual boundary breach was the Charybdis of other reactions. To respond to these difficulties and behaviours with a sexual response denies the client the opportunity to understand and change. There is a healthy use of sexuality – it goes with the territory – it‟s not about sexualising the relationship or even wanting to sexualise the relationship. One participant commented that lesser breaches than sexual relationships are incorporated into codes of ethics and practice. The first continuum was defined as early and small boundary breaches which needed to be understood in order to work therapeutically and to avoid more major boundary difficulties.but there is also a middle category ……„not working well‟ – sexuality is not spoken about and is put in a box.

Few referred routinely to the documents. Practitioners’ views of available ethical codes guidelines for ethical practice Views on the available guidance varied. a more positive experience of this aspect of their studies. Others found the training they had experienced on the values and use of the ethical frameworks to which they were committing invaluable. and hopefully. however. One possible interpretation from these accounts is that those who had been trained relatively recently had received more. and they reflected that with the experience they had accrued during their work. Several held the view that the practitioner needed to develop internal ethical principles which would serve as a guide.g. training on ethics and. subsequently. These were often appended by comments indicating that the practitioner regretted the way they had felt impelled to behave then. and decisions were made harder by uncertainty as to procedures and outcome. but which were felt to have had negative effects for the client. Regardless of time since training. more constructively. and this was understood eventually by the research 38 . Some practitioners felt a need for ethical guidelines to be written in terms of principles that would facilitate the balance of potentially conflicting interests. while worthy. there was a strong sense from some participants that the guidelines. as is already the case for some. Some of the variability could be attributed to the time since practitioners completed training. they would handle these events differently. Some held that their training and the ethical documents offered by their accrediting organisations were of little help in real-world practice.Many participants recounted examples of work with clients when anxieties and uncertainty combined. the BACP Ethical Framework. Alongside the conflicts with which practitioners struggled. did not help the practitioner manage the complexities of the clinical situation with its conflicting demands and competing ethical dimensions. and better. with the result that the practitioner behaved in a way that avoided a sexual boundary breach. e. there came recognition of a need to balance benefits and harms in relation to a number of stakeholders.

enabled the client to feel safe and provided the opportunity to experience and learn from the therapeutic space.team as describing a process analogous to the development of an internal supervisor (Casement. In other words. There was also a view. 1985). or even that therapy would not take place. these participants felt that the practitioner‟s attention to boundaries. that the ethical guidelines were intrinsic and integral to the work and that therapy would be compromised and limited. with its inevitable frustrations and reassurances. and their capacity to keep them secure. 39 . without adhering firmly to the boundaries. expressed by some.

and therefore vulnerable to having one‟s own emotions „stirred‟. indicating not only the difference between personal and professional roles but also the structural differences that characterise the interpersonal encounters between professional and client. he argues. while it simultaneously creates a sense of safety for the patient” (p. It is. Three issues are important to note at the outset.Chapter 4 The Therapy Work: Managing Risk In this chapter. Sarkar (2004) defines a boundary in professional practice as the distinction between professional and personal identity. a metaphorical term for the construction and limits of professional identity. made the point that sexual feelings are not the only emotions that may be „stirred up‟ between therapist and client. Third. the purpose of which is to keep both safe. whilst our particular focus in this study was management of risk of sexual boundary violations. as we describe in more detail later. dislike – can be evoked in therapy with potential for destructive and constructive impact on clients and also required work on the part of the therapist to manage for client benefit. 323). Therapists are not separate from the clients they 40 . Second. we draw out from participants accounts the processes involved in containing therapeutic boundaries. Gabbard (1997) suggests that the concept of the therapeutic frame “allows the therapist to be empathetic and warm. fear. although acknowledging the significance and ubiquity of sexuality and the erotic in therapy work. Other kinds of emotional responses – anger. clients may use sexuality or overt sexually charged behaviour as a way of avoiding or masking relationship difficulties or problems of intimacy more generally. Understanding and managing intimacy was therefore viewed as part of the territory that therapists have to negotiate routinely. From a psychotherapeutic perspective. the therapeutic encounter was seen by most participants as imbued with risk in the sense that engaging and understanding the „other‟ means that one is open and available to the other. irritation. many of our participants. First.

you‟re not doing the job properly…you have to get close to someone…you have to allow your feelings to get affected…we should be open or available enough to be stirred up…so that we are affected…it‟s not that we‟re detached in a way that they cannot affect us… we‟re not only scientists with them in that sense but there has to be the scientist feel. 41 . “working at the edge” have a particular meaning in some disciplinary frameworks. Other participants drew on such terms as „transference‟ and „counter-transference‟ from psychoanalysis to indicate role and relational confusion in the therapeutic context that requires understanding and management. for example. Some of the metaphors employed by participants. “You‟ve got to be there with them and detached enough to think about what‟s going on at the same time…you‟re not a detached observer…if you don‟t do the two. The essence is that the therapist is a participant in the sense of engaging with the client intensely.treat. Negotiating through “murky waters”. Metaphors used by participants of the process included: “Getting into – and more significantly – getting out of the mud”. as well as being an observer of the client‟s behaviour. They are both the objects of clients‟ feelings and subjects of feelings themselves evoked through their encounters with clients. reflecting on what is aroused in oneself. there at the same time”. “Working at the edge”. thinking about what it means. “Feeling uncomfortable – it goes with the territory”. Intimacy and distance (or engagement and separation) Most participants. like the analyst. from different theoretical frames of reference reflected that understanding and managing emotional depth necessary to engage with clients requires that the therapist simultaneously seeks to manage intimacy and distance. and working through how these are played out in therapy.

it is argued. considered that assuming the role of „observer‟ only or creating excessive emotional distance is as problematic as is engaging as „participant‟ only or over-involvement. Indeed. We use the term participant/observer drawn from ethnography as a way of creating a shared language that is not unique to a particular therapeutic framework. They can be difficult for the therapist to talk about openly. gestures or overtures by clients may evoke anxiety in therapist such that they “take fright …rather than stay [with the client] and think about what it means for [him/her]”. it is also becomes part of the work with the client. giving rise to anxiety about seeking support and guidance to deal with them in supervision. albeit it is informed by clinical experience. This effect appeared 42 . talking of supervising practitioners. Some participants thought that clients may sometimes become confused about the intimacy and closeness of therapy. as separate and engaged.The common element of the processes described is the therapist as simultaneously participant and observer. the work of therapy. Participants. treated as taboo or abnormal. Such a struggle is not only located within the therapist. Sexualised language. involves an ongoing struggle to sustain and manage the tension between the observer/participant dynamic. drawing on specific examples from their own clinical experience. said: “If I don‟t get to hear about any of that struggle… [I‟m concerned} that they‟re not aware of that potential intimacy …or getting confused…sexuality and boundaries can pop up and be broken in all kinds of relationships so if the murky waters aren‟t ever brought up [in supervision] then there is something not being thought about either in the client‟s world which is being projected onto the therapist …and things that aren‟t being processed…” In the context of managing the observer/participant relationship in therapy however. unable to separate out the therapeutic relationship from „real‟ relationships outside therapy and fantasise about the therapist as „girlfriend‟ or „partner‟. One participant. sexuality and sexual feelings present particular difficulties.

whilst the erotic and sexuality are seen as generally present in any therapeutic encounter. facing up to it personally. they pose particular difficulties of positive management in therapy because of the taboos surrounding them. formulating. including sexuality.across the accounts given by our sample. reflecting. Figure 4. . 43 . in therapy. our conception of this process has been developed both through exploration of concrete examples provided by therapists with different clients with whom they had worked more or less successfully and their reflections on strategies they had adopted n the face of difficult clinical situations. First. In the following pages. and using the understanding therapeutically for the benefit of the client.1 describes the individual components as: noting. Two points are worthy of note. processing. each and every element of the process set out here appeared essential toward managing emotional depth. It will be evident that guidance and support via supervision may be sought at any point or indeed at several points in the process. we describe the components of the therapy process that we have constructed from participants‟ accounts of their practice with clients in managing sexual or other intense emotional content in the therapy encounter. Second. In this sense. and was as apparent in independent practice as in specialised therapy contexts such as single gender residential settings. Box 4.1 provides a worked example.

curiosity.Figure 4. shame Reflecting Processing: Struggle to reach understanding and working through Developing a therapeutic meaning for these „real feelings‟/ symbolic thinking Owning a formulation: naming the situation Accepting situation without undue selfblame.curiosity Relief.g. Insight Disengagement from feeling Feeling more prepared/ armed Working with/ doing differently for therapeutic benefit 44 .1: The process of managing intense emotional content in therapy Engagement in therapeutic work and experience of relationship with client Noting Anxiety/ disquiet/ uncertainty Facing up to it personally: that there is an issue to be understood Reactions e.

in case an intervention has unintended consequences. before it for the client. 45 .1: An example of the process Using anxiety about boundary breaches to develop an intervention Younger female participant. however. through feelings of attraction. or unease. so that the therapy stirs up strong feelings in both the men and their female therapist. One key intervention was an interpretation that the qualities he was seeing in her. and anxious about acting without thought. who might act badly towards him if he were in her power Using therapeutically: This facilitated her in making links between his need for relationships and the difficulties he experienced with them (deprivations. working with male clients with a forensic history in residential settings. whilst at the same time he was resisting therapy work and it felt hard to work with him.in this example. and with experiences of past and current relationship situations Reflection: She reached an understanding that the client was acting and she was responding in order to mask another emotional situation that both found more painful or difficult to tolerate Processing: In reflecting on the client‟s situation and internal conflict. The participant identified dilemmas over how to deal with these feelings in session as a continuing area for development. Noting is a routine component of therapeutic sessions in these contacts. Clients often miss relationships with women and tend to see their therapist in the context of these absent and perhaps problematic relationships. feeling attacked.these situations may generate feelings related to the past and current relationships of the therapist. This intervention broke the sense of sexual tension.Box 4. frustrations and anxieties). and separating out what her own vulnerability and person contributed to the tension (observing self as well as other) separately from the client‟s contribution. she was able to start to manage her own response and refocus her emotions on her own life experiences Formulating: This led to developing a model for understanding the role or function of shaping up this situation in therapy for the client . giving rise to tension and awkwardness. and this means putting a name on it. The practitioner may feel uncertain about the way to manage these in the here and now. his questions felt provocative and scary Facing up to: This meant recognising the presence of tension in herself and realising that these feelings were linked to elements of her personal life. Key features Noting: The client asked her if her gestures meant she fancied him. This discussion went on over a number of sessions. Problematic dimensions of the relationship become apparent in sessions. she felt he was avoiding dependence on another.” This helps working on the issue with the client. “why are you acting as you are. There was a sense of sexual tension. were qualities he liked to see in a partner. feeling unsure about the client‟s reaction to discussing the issue. There is sometimes an additional area for thought in supervision . The participant reported using supervision to question. what it means for the client. This requires her to make a decisionwhether to act within the session or whether to stay silent about the experience and take the feelings to supervision.

What is going on here? Why do I find myself reacting more strongly than is usual for me? Why am I being affected? Why do I feel threatened in some way about what the client has said. „facing up‟ requires „normalising‟ these experiences and emotions as not being shameful in themselves. stance. Some immediate processing may take place within the session. It is both about what is going on with the therapist and what is being communicated by the client.Noting Noting is triggered by a heightened anxiety or sense of threat or an awareness of the clients‟ appearance. “…you get warning signs into your response where you think suddenly „ah this is a little bit…and I feel a bit too warm towards this person…that happens socially as well as in professional practice. This noting is a first step toward bringing to the fore. In a sense. Typically. how s/he presents him/herself? What is this communication about? How do I understand what‟s happening so that I can work with it for the client‟s benefit? Noting relates to feelings evoked in the therapist that may not be entirely sexual. to face up to. “I put the pause button on and think about this as a communication from the client…I tell my internal supervisor that this needs to go to supervision…to help me understand what‟s going on …I‟m in the murky waters suddenly…and I need to pause and reflect and take it back out of the session”. or behaviour. it is likely also to be identified and reflected on as something that needs to be taken to supervision. but may be “feelings for clients that were perhaps beyond the normal empathy or warmth…” Noting is about the feelings evoked in the therapist. and also the sense of confusion and uncertainty – being in two-minds – about what is going on that requires reflection and consideration. And so I suppose I tend to put the 46 . what is going on.

brakes on very strongly or to compartmentalise…you just split off the bit…just a self warning and just watching my own responses and the checking out of interventions I might make…” Noting requires sensitivity to the client. as in single sex residential environments: I might be sitting at the start of the session …and it could be just something…if I bit my lip not realising that I‟d done that. he would say: “…does that mean that you really fancy me”…so that sparked something in myself that kind of feels unsafe…I need a lot of guidance in how to work with him because the sessions –he‟s really difficult to work with he‟s very negative and it‟s very hard for him to take on help because he‟s always got something to push back that would automatically be something about his erotic fantasies…so that is quite difficult for me”.” There are particular work contexts in which overt sexual advances may be made by clients. such situations also required antenna sensitive to noting. Participants made a distinction between feeling sexually attracted to a client and finding the client attractive in the sense of being likable which meant that work with such clients was experienced as particularly enjoyable. and a sense that this is something that needs to be picked up and examined: “I took it to supervision …part of it was a response to the client‟s stance and use of sexual attraction in her relationships generally…understanding it more made it possible to get to a more contained experience. in part because of the danger of holding on to clients when therapy had come to a natural end. Yet. self awareness on the therapist‟s part. “I‟d watch the imagery…one of the tests would be if one was becoming too socially engaged without elevating therapeutic discourse to a special plane 47 .

On occasion it can be dealt with in the session. “Sexual relations can be played out within session material but there‟s that boundary of whether you act on it and how you dissect the information and use it appropriately if you feel that that‟s something that can be brought up within the session …there‟s that real sense of nervous tension…that can be awkward that I‟ve experienced…so if there‟s a place where I can look at them with them then I will…I found it useful with the supervision to help me come back to that…I‟m unsure of how to handle it in appropriate ways so sometimes [in the session] you sort of pretty it up and try to push it back a bit because you don‟t know how to look at it…” Personally facing up to it may involve both an immediate internal response and a compartmentalising of aspects of a response pending further discussion and reflection in supervision. the therapist did not immediately respond. considering that the client had come with relationship issues of which this was a 48 . it nevertheless involves a further stage of reflection as in: „This is something I have to deal with. Practitioners may decide to refrain from acting on their thoughts or feelings in the session. and may store their experience for later examination and reflection outside the session. Whilst feeling personally threatened and internally reflecting that this was a clear „no-go‟ area. It may also be taken to supervision to consider how it can be worked through. this needs to be brought to the fore and worked through‟. Facing up to it personally Facing up to it is linked with noting.which is different…its when you realise that you‟re talking to a client…as if with friends…that tells…that the work has come to a close or reached a point where …there‟s not much more to do and that‟s the point to stop”. One participant recounted how much earlier in their career. a client had indicated at their first session a desire to have sexual intercourse with the therapist.

on the other. Instead. the feelings generated in them may relate to their sense of being responsible for the progress that was achieved. and a level of honesty and integrity to „name‟ what is going on. 49 . Reflecting and naming may take several sessions to achieve. it was taken to supervision to continue the process of reflection and formulation. whether that could be something to do with my past. Reflecting This is the process of separating out the meaning and significance for the therapist and for the client.manifestation and to explicitly reject the client would have been non-therapeutic. It also requires being able to go beyond self to focus on the client. my own relationship…and why I might be feeling something toward someone in the group or why they might be feeling something toward me”. It implies self-reflexivity – self awareness and knowledge on the one hand. of what generated the heightened anxiety in the therapist: ”I want to look at it the right way and not make them (clients in group work context) feel scared or awkward or bad for having those kinds of feelings it‟s important that I understand why those feelings are evoked in me. “…with the one person … and that also made me think about maybe I see qualities [in the client]…that actually I like in my own relationships…I don‟t think you really think about that…” For therapists as well. separating out and „naming‟ what is going on for both therapist and client. It takes conscious effort on the part of the therapist since it involves facing up to what can be difficult areas of experience. Reflecting is about pulling apart. “… There was something about being able to see that progress…that part of me that felt like a proud mother”.

Reflecting is distinguishable from processing which is the next phase. their degree of comfort in their sexuality or. This is where knowledge and skill comes into the equation: how to work through the meaning and implications of the feelings generated in the encounter for the therapy work. These may include experiences or events in the practitioner‟s own life. The reality of my life is that sometimes there may be days or even weeks when I have very little contact with my friends. Processing Processing involves working through possible solutions that will be beneficial to the client. “I recognise that I need to take care and monitor situations when I am not personally in a relationship: it is not appropriate for me to try to meet my emotional or physical needs for contact through my client work.because you could feel this kind of sexual tension within the group but no-one was willing to put a name on it…I went to supervision and discussed it…” Part of the processing may include awareness of contexts in which the therapist may feel particularly vulnerable. for example. clients cannot be a substitute for these relationships. conversely. the strength they derive from their own relationships. difficulties in their personal relationships at that point in time. “One client [in the group] I was very aware of…what is it that he‟s stirring up in me…there were feelings on his side that we looked at…qualities they say in me that they would like in their own girlfriends…in their own relationships…we looked at . positive or negative. 50 . I try to meet my emotional and tactile needs through a network of friends. Being able to work through this in supervision was seen as helpful and indeed a necessary part of the process – on the assumption that the supervisor would be open to explore such „tricky issues‟.

Reflecting. Inexperienced therapists may respond to anxieties by erecting rigid boundaries. how does the therapist respond to a client who acts in a flirtatious manner whilst not damaging the relationship? One participant described how one client would flirt in therapy. There may be vulnerabilities relating to the work context. Over time and through engaging in the processes described above. and began to use this formulation to explore the client‟s concerns and anxieties in a manner that was neither confrontational nor rejecting. particularly with a supportive and supervisor seemed to enable the practitioners to learn and develop confidence in mastering the participant/observer stance. For example. Formulating Building on processing is formulating and developing strategies for use in relation to the client. and there are times when I must actively re-establish intimate connections with those closest to me. 51 . “…and then I went back to the group and it was the same kind of atmosphere (sexual tension) and I was able to put a name on it… and…I think some of the qualities you see in me are some of the qualities that actually you‟d like in your own relationships…there was this sense of relief that this sexual tension had been broken…and that‟s really hard to do…” An aspect of formulation involves thinking how to contain sexual feelings whilst working therapeutically with the client. as for example. the practitioner came to understand the flirtation as an attempt to manage status. acknowledging that these may be times of emotional vulnerability”. female therapists working with male offenders in an all-male environment. uncertainty and control in the sessions.this connectedness.

but were used in the development strategies for therapeutic benefit.were important factors in enabling them to manage the intensity of the therapeutic work. practitioner emotions were not acted upon without awareness. The process model was created through analysis of what seemed to work positively for therapists and clients. formulating then using the understanding therapeutically for the client were seen as the way the best work was done. we have examined the nature of the therapeutic encounter and the processes involved that facilitate management of risk of sexual boundary violations. In the next chapter we examine some of the specific examples recounted by therapists where they experienced particular difficulties and the lessons drawn from them. place and nature of the relationship .e. A common theme from participants was that „therapeutic boundaries‟ – those that defined the therapy space such as time. Summary In this chapter. The processes of reflecting. 52 . It represents an ideal in that therapists also viewed the process as one in which they were engaging in an ongoing struggle. i. This is the space that participants described variously as „murky waters‟ or „the edge‟ – spaces that were „scary‟ but at the same time where the therapist was most sensitive to what was going on with the other person – whilst also self consciously aware of their own actions and reactions.Working for therapeutic benefit This may include strategies to both stretch boundaries and retain/reinforce bounded areas – but the focus is on how to use the understanding therapeutically for the benefit of the client. Using the understanding therapeutically for the client may mean that the therapist chooses the opportunity to pose „tricky issues‟ – when it seems most appropriate for the client. processing. containing it within this environment.

” By not responding defensively and by naming the behaviour openly. The professional literature emphasises that practitioners “need to be able to differentiate between sexual 53 . Sexuality as ubiquitous in therapy As we have discussed in previous chapters. we explore what were perceived as problematic responses to the management of sexual boundaries. These views echo findings from research elsewhere. Pope.this was seen as abuse of the client. the therapist provides a boundary stabiliser within which underlying issues around loss and commitment can be explored and worked with. Responding appropriately requires “staying with the client.. Keith-Speigel and Tabachnick (1986) found that the majority of practitioners responding to a survey indicated that they had at some point been sexually attracted to their clients. not “sexualising the therapy relationship or even wanting to sexualise the relationship”. either by the participant or another. Further. practitioners also recounted instances where they experienced sexual attraction to clients. We then consider those professional and organisational boundaries found helpful by therapists in containing the therapeutic space.Chapter 5 Problematic Strategies and Creating Safe Boundaries In this chapter. Key however was not acting on it. Thus.. not running away” thereby allowing “the therapist to think about what this meant for the individual. Clients‟ sexual overtures. while evoking uncertainty in the therapist. such as supervisor or the research team. most practitioners viewed sexuality as a universal feature of the therapy experience – one component of the difficult emotions that arise in therapy. focusing on specific examples from practice. can also offer clues to deeper problems in relationships that they find difficult to communicate and master.

which is unethical and destructive” (Thoreson. which is inevitable. who was attracted to the client.. The client never returned and discontinued therapy. Sexuality: Problematic responses Alongside accounts of successful management of sexual boundaries in therapy situations. The practitioner felt in retrospect that this defensive response related to lack of experience and ability to work with the attraction. being a newly qualified therapist. and over-protective anxiety. neediness. and from which they had learned. Self-protective/defensive Practitioners offered case examples of situations in which fear or anxiety relating to possible therapeutic boundary breaches led to them reacting in an unthinking. defensive and sometimes punitive manner without anticipating the impact on the client. Now.attraction. these stem from therapists‟ inability to manage in the moment the simultaneous participant/observer stance. deflected overtures to meet socially by reinforcing therapeutic boundaries “…this is therapy and we‟re here to work for your benefit…and there‟s no point coming otherwise”. sometimes from early in their careers. In the first example. Even so. the ubiquity of sexuality in therapy did not mean that it was easy to manage attraction appropriately and for client benefit. moralising/omnipotent. We have characterised these problematic responses into four main types: self-protective/defensive. when they had handled individual situations in ways they felt they would not wish to repeat. while avoiding a reportable boundary violation. the practitioner. as the complexity of the process described in Chapter 4 attests. Shaughnessy and Frazier (1995:88). Others recounted recent events that. some participants also described events. had results that were considered problematic or unsatisfactory in some way. and sexual acting out. with experience the focus would be on: 54 . In different ways. whether to the participant or the research team.

The therapist perceived that their “failure to appropriately manage the relationship” was a factor in the client‟s relapse. suggesting that they might meet socially. this was declined and the client subsequently experienced a mental health crisis in which fantasies relating to the therapist featured. responding to this as indicating a „real‟ attachment. conveyed to the client that this was impossible and the therapy ended. The organisation offered the client another therapist. One specific account here referred to a client who had experienced long-term. Some weeks after therapy ended. In one of their therapy sessions. and where it may be easier 55 . then with each individually for a number of sessions after the relationship broke down. The therapist reacted with surprise. that I did get the manager to send a letter warning the client off…I was just afraid of my own reactions and wanted to put some kind of sure line down…I felt too threatened…now I perhaps would have suggested we talk about it in a session perhaps…” The sense of guilt and shame expressed by therapists reflecting on self-protective action reinforced their view that it represented poor practice in not fully taking into account the impact of their behaviour on clients.“…thinking how to use this therapeutically…to understand the transference and counter-transference and link it back to issues in the person‟s life and use the material to help them think about what they‟re doing in their life outside”. Protective/defensive responses may also reflect practitioners‟ fears about being pushed into areas that they personally find very uncomfortable. A second example concerned a practitioner working with a couple. the client waited outside the therapist‟s workplace after normal working hours and approached the therapist. Participants also provided examples to indicate how clients were adversely affected by self-protective action on the therapist‟s part. “I [therapist] made my excuses and left…I feel more ashamed of this now. severe and enduring mental health problems and came with additional marital problems. the client declared love for the therapist. who was leaving.

whilst ostensibly „protecting‟ the therapist professionally. I can‟t cope with it”. Grunebaum 1986). or unreflective acting on heightened anxiety and fear. they occurred across mixed gender encounters – female therapist/male client and male therapist/female client as well as same sex encounters that involved gay and heterosexual therapists. therapists may conduct themselves in this rigid manner with a conscious intent of reassuring themselves that they are beyond reproach in an ethical sense. Further.” We found that self-protective action did not define the general stance of most participants. these kinds of encounter were not unique to either male or female therapists. A self-protective/defensive action and stance does however indicate an inability to manage the duality of the participant/observer relationship in this particular moment of a therapy encounter. Gabbard (1997:323) argues: “Maintaining excessive emotional distance from the patient can be a form of counter-transference rigidity masquerading as ethical adherence to professional boundaries.e. Here. Thus. instead of engaging with the client. i. selfprotective action is illustrative of how the taboos and fears in this area lead to rejection of the client. Second. the therapist symbolically pushes the client away. Third. Thus: 56 . defensive and self-protective responses were considered problematic and arising out of either lack of skills or experience. self protection on the part of the therapist could have adverse. based on practice experience (Gabbard 1997. which is often the end result. Several points are worth noting here: first. In such cases. destructive consequences for the client – a conclusion that is also drawn out from the professional literature. in the context of sexualised behaviour or sexual overtures on the part of clients.to think: “I‟m going to finish with this person because I‟m not doing them any good…but really it‟s because I‟m finding it too painful. they indicated they had learned from their experiences to reflect on their own response and would formulate and act differently now. further. The unconscious intent may be to drive away the patient.

this also flows from the therapist failing to manage difficult situations. Moralising/omnipotent Another type of problematic response in managing boundaries is what we term „moralising‟ or „omnipotent‟. then taking a stance that increases separateness and distancing themselves from the client. therapy cannot work well. As with the protective/defensive response. the therapist can relieve themselves of anxieties about incompetence or guilt. 57 . may be the adoption of the position of expert. Here. it was acknowledged that when “sexuality is not spoken about and is put in a box”. An additional element of this. very distressed …that‟s not very good for the patient but it protects me. One example here draws attention to the tension between establishing boundaries to create a safe therapeutic space and adopting a rigid approach in controlling what can be explored within that space. the practitioner talked about an experience with a client described as very lonely and „needy‟.” Yet. Here it was not the reinforcement of the therapy boundary in itself that was seen as problematic but in the way it closed off exploration of the client‟s „neediness‟.“…there comes a point with these sexual boundaries and intimacy boundaries where …the imperative is to protect oneself professionally…even if it leaves the patient very. the response was to “state loudly and explicitly that therapy was not the place to be comforted …or for socialising”. Considering that the client was seeking a degree of intimacy that was considered inappropriate. and of the previous strategy. as if by putting the client in the wrong.

both in terms of the quality of engagement or of managing intimacy and sexuality. “It happened in a session that was scheduled for 50 minutes but which lasted about two hours…I was so encumbered by the awfulness of it…I identified much too closely and much too intimately with this parent‟s experience because this was one of my most profound fears…” At the time. that if you can‟t bear to hear what I‟m saying. In this example. provided accounts of over-identification with the client‟s difficulties based on their own neediness that posed a risk of problematic responses to managing boundaries.Neediness/over-identification Participants emphasised the significance of self-understanding and of being grounded in their own personal relationships as crucial for maintaining the observer/participant stance. if not explicit feelings of sexual attraction. this was subsequently assessed by the therapist as being a boundary breach in terms of over-identification. I‟m going to stop coming because I feel what I bring to you hurts you too much to hear it”. at particular points in their lives or where they were experiencing relationship difficulties or losses. What might appear simply as organisational constraints that at times can be seen as 58 . Some. horrified and pale. the therapist indicated that it was the client that brought it to attention saying that: “You look shocked. It is of interest here that formal boundaries marking out the therapeutic space – as for instance the timing of sessions – help to create a safe place within which therapists can engage appropriately with the duality of intimacy and distance/ participant and observer. the participant described emotional turmoil evoked in respect of a client whose child had died..

in fact help to sustain the therapy encounter as a specific form of contact whose purpose is to be of benefit to the client. In another example. In retrospect “I think it might have been better not 59 . and at the time of the interview still wondered whether the feelings were based on real compatibility. they had unthinkingly responded to the client‟s anxiety in a way that subsequently made them question whether their actions might be construed as straying across the appropriate therapy boundary in order to provide care that was later seen as possibly inappropriate. One example was when the therapist gave their personal telephone number to a client with the explicit purpose of offering reassurance over a break.arbitrary or even inhumane. the experience gave rise to questioning about whether such emotional responses should be discussed overtly with clients and whether such openness could have been therapeutically useful. or was anxiety-driven. Over-protective anxiety Some participants reflected that on occasion. this was felt to be a difficult experience. 1987). 2005). This issue is also linked with different interpretations of the professional role in some therapeutic approaches. Those with difficulty in separating out from a significant relationship may find intimacy hard to achieve”. the discussion in Gabriel. Whilst this was not discussed nor acknowledged and therapy continued to what was evaluated as a positive negotiated ending. for example person-centred therapy (see for example. Gabriel (2005:32-33) suggests that “…intimacy between client and therapist is a complex and potentially problematic area of therapeutic relating…” and drawing on Holmes (2001). the therapist described being very attracted to a client and felt this was mutual. resulting in having to bear feelings of longing and anguish over a period of time. she notes that “the paradox of intimacy is that we can only achieve it if we can negotiate separateness successfully. Although the therapist did not act on the feelings of attraction. Whilst some person-centred therapists consider the possibility of an expanded therapist role beyond the traditional therapy hour (Thorne.

Touch was cited as one of the demonstrations of overprotective care. She opted for a compromise she felt was unsatisfactory. overinvolvement means that the therapist in becoming engulfed in their own emotions and needs. For the supervisor. problematic responses to sexuality and intimacy issues in therapy can be viewed as different ways in which the struggle for the dual participant/observer stance is not achieved. may adversely affect understanding of a challenge to boundaries. allowing the client to hug. this was viewed as indicative of lax boundaries. she described the impulse to reject the hug. or alternatively thinks. The result is one of 60 . Another example was drawn from a participant as supervisor who challenged a supervisee on the use of their mobile phone for engaging in text conversations with clients outside of the therapy time. On these occasions. and personal characteristics. In summary.to…whether you would call it a boundary breach…but it was probably a mistake…sometimes you do these things and you don‟t know whether they‟re right or not”. and a matter of concern. Anxiety. One participant spoke of the conflict experienced when a client moved to embrace her. either the therapist acts on the basis of feelings or assumptions. alongside an anxiety that the client would feel personally rejected. and similarly loses sight of the client‟s emotions. without reflection. perhaps without concern for the client‟s state. including one's history and perspective on the world. but in a detached way. lack of knowledge and experience. Being pulled in either direction – either toward the detached observer or participant stance means that one ceases looking at self in relation to the client for the purpose of benefit to the client. Whereas self protective and moralising strategies remove the therapist from considering what is happening with the client. but putting her hand on the client‟s shoulder to limit it and in what she felt was a maternal fashion in order to prevent it being mistaken for anything other than innocent. resulting in detachment.

either alone or through discussion with another. e. What was clear. The relationship between these problematic reactions and strategies and the process followed by practitioners as demonstrated in Figure 4. might make it possible to move on from the strategy. in supervision. with an understanding of the significance of the reaction. The list of reactions identified has been drawn from participants‟ accounts. 61 .g.these less desirable reactions. was the recognition that although each problematic strategy disrupted the process. The problematic reactions disrupt the process of working through the meaning of boundary breaches or feelings in relation to boundaries and clients.1 in the previous chapter has been developed into an amended process as illustrated in Figure 5. through incapacity to think through the meaning and implications of actions. the practitioner could resume working through the process. reflection. however.1 below. but is unlikely to be exhaustive.

Figure 5.1: Problematic responses to intense emotional content in therapy Engagement in therapeutic work and experience of relationship with client

Losing the balance between participation and observation Noting Anxiety/ disquiet/ uncertainty

Avoiding, denial misunderstanding

or

Facing up to it personally: that there is an issue to be understood Reactions e.g. curiosity, shame Reflecting Denial, irritation, pathologising the client, infantilising, or infatuation

Processing: Accepting situation without undue selfblame- curiosity Struggle to reach understanding and working through

Developing a therapeutic meaning for these „real feelings‟/ symbolic thinking

Blaming, over-protective, becoming the „expert‟/ authority, considering feelings are real

Owning a formulation: naming the situation Relief, Insight Disengagement from feeling Feeling more prepared/ armed Working with/ doing differently for therapeutic benefit Seeing the feelings as generated by the client‟s problems, experiencing the relationship as real

Acting on the feelings in punitive, over-protective, seductive, demanding, exploitative or paternalistic ways

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Chapter 6
Supervision
This chapter covers the functions and experience of supervision as described by the participants. Given that there was a sense that participants offered supervision as the primary, and first, source of support for developing constructive responses to potential threats to therapeutic boundaries, the area seemed to merit specific exploration.

Supervision, professional context and training Supervision was seen to take place within a professional context, which included the work environment, colleagues, employer and professional community. The expectations on a practitioner to undertake supervision were seen as crucial, and there were observations that some organisations did not require or ensure that supervision was available or took place. Colleagues and links with a professional community were viewed as a potentially important influence, for good (but occasionally poor) practice, and isolation was identified as a risk. It was recognised by some participants that supervision skills themselves require training and reflection. Several suggested that supervision needed to be included in training, and that supervision of supervision is valuable, or indeed essential.

The functions supervision is seen to serve In their accounts, participants treated supervision as a support for learning in the face of anxiety and uncertainty, and that the capacity of the supervisor to contain anxiety was in itself an aid to learning. The process usually described was a sequence of discussion of the case, reflection on feelings, behaviours and concerns, and new understanding, often followed by resolution (at least to some degree) of uncomfortable emotions, sometimes advice, and a return, hopefully better armed, to the therapy situation. There was a theme around supervision being “fit for purpose”: some participants noted the challenges of the

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possible range in personal styles of supervisor and practitioner, and the effects each working with different models, and of the necessity of allowing sufficient time to move “beyond discussion of techniques”. The core aims for supervision held by participants were therapeutic benefit for clients and the development of therapist skills, but there was a strong sense that supervision was a professional standard in itself and a means of upholding professional standards. One participant described the need for supervision as “as important as insurance, or having a proper consulting room… necessary to do the job properly.” Another stated that “regular supervision and contact with the professional community should be part of codes of ethics.” Several participants commented on the need for the supervisor‟s approach to fit with that of the therapist. This did not seem to require that the two use identical models. However, some participants considered that where there was a lack of congruence between the approach adopted by supervisor and therapist in regard to what was deemed an appropriate ethical stance, it made it harder to manage problematic situations. This might include for example, differences of opinion over boundary issues, such as use of touch. . Supervisors were seen as more knowledgeable and their advice on ethical issues taken seriously. While the majority of the participant accounts suggested that supervisor responses were experienced as understanding and thoughtful, two participants described examples of taking concerns about reporting issues to their supervisor from early in their careers. These accounts illustrated two different and problematic responses. One participant was concerned about a client‟s professional conduct. When this was discussed in supervision, the supervisor had advised that the boundary breach being described needed to be managed therapeutically rather than through reporting, so that the participant struggled over the issues with the client for some time. It seemed to the interviewer that in this instance, the practitioner was still left with questions. A second participant felt that the concerns he had outlined about a colleague‟s professional conduct to his supervisor were taken by the supervisor as indications of his personal pathology.

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the supervisor might note any signs of the practitioner‟s self esteem being overly dependent on clients‟ improvement. 65 .Participants expressed the view that supervisors have a role in maintaining ethical standards. staying “alert to potential risks” and to “small breaches”. Once contracted for. and encourage the use of personal therapy when this seemed appropriate or helpful. it was felt by some participants that the issue might be proactively included in contracting in relation to general boundaries. the supervisor might beneficially question the practitioner on the presence. and that the skills to enable practitioners to talk about embarrassing personal material was important. Contracting was seen as important to good supervision and protective for situations where sexual boundaries were discussed. Four participants felt that they have responsibility to “look for issues around sexuality” and need to be aware of potential indicators of risk. It was seen as positive that supervisors might discuss the ubiquity of sexual feelings during contracting and then continue to take the position that discussing issues around boundaries and sexual material forms a routine part of supervision. Given that sexual breaches are only one type. such as fantasies about clients. One participant felt that a supervisor had encouraged more self-revelation than felt comfortable. This included discussion of the possible actions required of the supervisor should there be any particular concern about the practitioner‟s professional conduct. participants felt that the supervisor needed to keep a boundary between supervision and personal therapy. While it seemed important that supervisors allow practitioners to make links between personal issues and their involvement in the therapy work. and found the experience unhelpful for the therapy work. Making the roles and professional responsibilities of each participant explicit at the start was seen as beneficial. A further area of concern to participants was the way the supervisor handled situations where personal material of the therapist was relevant to the discussion of the client material. or any sense that the therapist might feel “special”. In particular. extent and nature of sexually related material. then in discussions of clinical material.

and there were references to supervision as a safe setting. one psychoanalytic. Some might feel unprepared for managing sexual boundary threats early on. and might need more practical guidance at this point. whether for client or practitioner. in some circumstances.Some participants noted that supervisor and practitioner might have been trained in different models of therapy. Practitioners valued clear and explicit boundaries. 66 . including accounts which might give rise to embarrassment or shame. A particularly invidious combination was the practitioner with more liberal boundaries than the supervisor. Supervisory tasks: Managing the setting of supervision Participants expressed clearly what they felt was required of supervisors in relation to both the supervision setting and supervisee. One valued boundary was the confidentiality offered by the supervisor. The supervision setting was seen as “a space to talk honestly about uncomfortable material”. The feelings of rejection attributed to one and the approbation of the other might. There was a concern that this might at times be difficult for the practitioner receiving supervision. who was experienced as punitive and pathologising. The other. was experienced as understanding and accepting or normalising. and to the clinical work brought by therapists. All these were viewed as essential areas for supervision. and that some boundaries might have different meanings. This situation made the interviewer aware of the risks for practitioners inherent in working with two supervisors. It was recognised that practitioners might need different responses from the supervisor depending on their level of experience. These included attention to boundaries in supervision itself as well as in clinical work. those that showed how the practitioner might be struggling and perhaps reluctant to discuss their plight. Supervision was seen as a “place for truth”. and those where there had been a “little slippage”. limit the value of the supervision offered by both. from a humanistic background. in order to avoid bigger errors or breaches. One participant compared experiences with two supervisors. and for talking over issues that it might not be beneficial to make public or note down. enabling the practitioner to clarify what was expected.

it was felt that the supervisor needed to be able to facilitate openness and honesty. Twemlow.In order to make most use of this aspect of supervision. 1997). in which the therapist can feel confident that their disclosure will not shock the supervisor nor fear attracting judgements for admitting to sexual fantasies. It was noted that supervisors are only human. however. One participant‟s account included an example in which their personal issues around sexuality were seen to have played a part in the supervision. Both contracting and the supervisor‟s response to difficult material were considered important. This needed sensitive exploration. These accounts resonate with the recommendation that supervisors need to understand interpersonal dynamics. and reported it as a lost opportunity to learn something helpful for the therapy work. 2005. and facilitated exploration and “honest self-evaluation” by the supervisee. one expression of which might at times be a feeling of sexual charge within the supervision session that might repay reflection. even while recognising the need to. Another expressed disappointment that a supervisor had seemed embarrassed when there was a moment of sexual tension. One valued characteristic was a supervisor‟s capacity to remain calm (rather than become anxious) and therefore able to explore. Three participants spoke of a “parallel process”. including those elements that might be drawn from past experience (transference and countertransference) (Gabbard. is also found in the literature (Ladany. 1997: Garrett. This need for a safe environment. dissipated. The supervisor might participate in discussions on the effect of personal issues on the work. and feelings that felt incongruous to the practitioner (such as disgust or love). ask “difficult questions”. role misunderstandings and difficulties including abuse (sometimes these were framed as transference and counter-transference). 1998). Nearly half of the sample emphasised the importance of avoiding a punitive response. 67 . some participants reported that the tension resolved and sexual feelings within supervision and therapy with the client. After discussions which were managed well. These might require the practitioner to reflect on the effect of their internal “dynamics” might be involved in supervision as well as in the clinical situation. Interested inquiry both acted to assure the practitioner that this was an appropriate supervisory task. at times.

For example. This might involve monitoring the engagement and reactions of the supervisee. This might mean making sense of small cues. and make it more possible for the therapist to regain their therapeutic equilibrium. it was expected that the supervisor would be in a position to notice and initiate a discussion when concerned.Supervisory tasks: The activity of supervision The primary task of the supervisor. “often symbolic”. Successful supervisors were seen as holding complexities in mind. One participant described the way a supervisor would remain aware of the different experiences of both the therapist and their client. and then bringing them into the discussion. a sense of pressure in the work. this might involve making links between the two. It was noted by some that this is important when the client has experienced difficult past 68 . they assisted the therapist‟s understanding of an anxiety-provoking situation. The next stage involved developing the therapist‟s understanding that their feelings of attraction may have some meaning for the issues the client brings to therapy. however. In this way. perhaps to be special or to make a success of the case. with the aim of reducing the practitioner‟s anxiety and capacity to respond without thought or an impulse to self-protection. they took into account the two relationships (therapy and supervision) and would attend to issues in both as appropriate. and that understanding their own response might facilitate better understanding of the relationship with the client and the function of the feelings for the therapy encounter. balancing these and taking both into account. which would limit or remediate boundary breaches. At other times the focus would be on one. At times. A further task for supervisors to undertake was to help the practitioner to develop a stance or even guidelines for future sessions. In terms of sexual aspects of the work under discussion. One tension inherent in the task was between normalising and problematising experiences in relation to threats to therapeutic boundaries. such as a feeling that the practitioner is not bringing their experience of sessions for supervision. “naming” what seemed to be “unsaid”. was seen as joint “meaning-making”.

that the supervisor help the therapist consider whether and how their activity in the session might repeat or sustain the client‟s experience of abuse. Gabbard (1997) also commented on the problem of supervisees keeping secrets from supervisors. between issues described at assessment and the development of role relationships during the course of therapy. and also facilitated reflection and making links. noticing anxiety about a session. e. As the practitioner developed.g. understanding of their experience increased. The supervisee’s role and responsibilities The final area mentioned by participants was the supervisee. the therapy relationship and their own engagement in the work. even when there might be cues that were suggestive.experiences with similarities to those occurring in the sessions. Once these had been disclosed. e. The supervisees‟ task included nurturing the development of their own internal supervisor. It was therefore for the therapist to be as open and honest as possible about their work.g. When the therapist felt under pressure. and was not always in a position to know of breaches without being informed. 69 . It was felt that the primary responsibility for the client work lay with the therapist. 1985). and implicit in the accounts of others. was “the internal supervisor” (Casement. mentioned by four participants. A key concept. and to include their difficulties and reactions. a feeling or a response. A distinction was made by one participant between a “healthy internal supervisor” and one that might be “harsh and judgemental” or one that was experienced as “sitting on my shoulder”. The supervisor was facilitative. and then informed future practice. facilitating the adoption of options and means of managing oneself in sessions. the healthy and experienced internal supervisor would be mindful of the possibility of acting out and how destructive it could be. and ”small breaches” in spite of discomfort. it was the supervisee‟s responsibility to explore these. This allowed the therapist to note what might need to be taken to supervision.

One participant described the guidelines as offering a “safety harness”. A model for working in supervision Figure 6. systemic factors can either impinge or support. sometimes implicit.An interesting development of this concept seems to be the recognition. It is possible to see here a reference to the place in which the „murky waters‟ are „stirred up‟: the area of discomfort and struggle.1 shows a model for working in supervision that arose out of our higher order conceptualisation of the material described above. and defended against. This place is in the overlap between what is in full awareness and comfortably known. recognising that if their therapy skills failed them. as can the supervisee‟s development of her or his internal supervisor. While this is clearly an important issue in training. and what is underneath or at the edge of awareness. 70 . The degree to which supervisee and supervisor are able to work within this area is determined first and foremost by the level to which the supervisee is able to feel safe within the relationship. there remains an element of this that cannot be controlled for. of an “internal ethical committee”. Our participants variously described this as “the edge”. “the mud”. and various other evocative terms. at least they could return to their ethical stance and moral code. the capacity to use the boundaries therapeutically develops from this initial reliance on the guidelines. However. One participant described this as an “internal „No‟”. Several participants seemed to have made a distinction between the therapeutic elements of their activity and the ethical. Later. the capacity to internalise and manage ethical standards seems to develop over time.

These form a mirror image to the practitioner‟s own roles. however difficult it might be for the therapist. by monitoring the therapist‟s accounts and their own experience so that threats of boundary breaches might be brought into discussion. the supervisor is seen as providing a quality check. There are several roles outlined for supervisors. 71 . we have considered the supervisory relationship. with the intention that violations might be avoided or at least remedied through reporting. management of the supervisory relationship and contracting. and with theory-practice links.Figure 6. and there are potential contributions supervisors might make to support and develop therapist work at any point in the process model described in Chapter 4. these comprise a focus on client benefit.1: A model for working in supervision Systemic factors + - Supervisor brings issues into awareness The Murky depths Issues remain hidden in the depths + Internal supervisor / monitor Summary In this chapter. facilitating the development of the practitioner‟s capacities for understanding and working therapeutically. Clinically. In addition. and note the high expectations of supervision as an activity.

The model represents an ideal in that therapists also viewed their capacity to work through threats to boundaries as demanding. (3) reflecting. we drew out from participants‟ accounts the processes involved in containing therapeutic boundaries and developed a model created through analysis of what seemed to work positively for therapists and clients. these were experienced as a struggle that might be extended over several. There is a section outlining the strengths and limitations of the study. (6) working for therapeutic benefit. with reference to future research areas. How do practitioners manage these in their therapy work and what are the effects of such management? The findings range across a number of areas relevant to clinical practice. followed by a discussion of the implications for practice. What do practitioner accounts tell us about the indicators that signal potential or actual sexual boundary violations by practitioners in their work with clients? 2. Research questions and summary of the findings This study sought answers to two research questions. Participants felt that successful outcomes for their work with such situations resulted in increased understanding of the client‟s difficulties and often therapeutic benefit. When threats to boundaries occurred. (5) formulating. The concept of the participant/observer. (2) facing up to it personally. In Chapter 4. Conclusions and Practice Implications This chapter includes a summary of the key findings. provided a model for making sense of the participant‟s experiences of both engaging with the client and 72 . sessions.Chapter 7 Summary. including recommendations derived from the research. or even many. namely: 1. Finally the chapter ends with general conclusions. This model articulates the following process: (1) noting. (4) processing. taken from research contexts.

These were: self-protective/defensive. A focus specifically on accounts of supervision experience and expectations for supervision indicated that practitioners have high expectations of the activity and of supervisors. While many of the accounts suggested that supervisors were found to be helpful. and there are potential contributions supervisors might make to support and develop therapist work at any point in the process model described above. The processes involved in these reactions suggested that the model of boundary containment remained apposite. update or extend understanding of that experience. There are several roles outlined for supervisors. if it were deemed necessary for the protection of clients and the profession. management of the supervisory relationship and contracting. participants not only affirmed the value of clinical supervision in order to help practitioners avoid or at least remedy breaches to the benefit of the client. the analysis of clinical accounts identified problematic reactions to the need to manage sexual boundaries whether identified as such by the participant themselves or the research team. on the one hand. and over-protective anxiety. facilitating the development of the practitioner‟s capacities for understanding and working therapeutically. In addition. Clinically. and . moralising/omnipotent. there were several instances of disappointment where participants had felt they were faced with criticism. where issues were avoided. but also felt that the supervisor had a responsibility to report unethical activity to the practitioner‟s accrediting organisation. and with theory-practice links. These mirror the practitioner‟s own roles. 73 . neediness. the supervisor is seen as providing a quality check and has a role in maintaining standards and ensuring ethical practice. or where supervisor guidance left them with unresolved feelings and even wondering about ethical dilemmas. Furthermore. these comprise a focus on client benefit. on the other. however difficult it might be for the therapist.participating in the experience of the session. taking a step back to reflect on. In Chapter 5. This occurs by monitoring the therapist‟s accounts and assessing their significance alongside their own experience of the supervision so that threats of boundary breaches might be brought into discussion.

some had come to regret the reaction and its effects on the client. in at least one. clients left therapy. suggested they had differing degrees of awareness at the time of acting. that some reactions to concerns over boundaries increased the practitioner‟s understanding and resulted in further therapeutic development. as the therapist attempts 74 . Our findings. The way that practitioners handle the experience of small boundary breaches therefore seems to have significance for skills development in future therapeutic work and may repay attention. The team developed a sense during the analysis of the characteristics of problematic reactions to threatened violations. there was a suggestion that the event was a contributory factor in further mental health difficulties. Punitive responses and the potential for harm to clients have also been discussed by Simon (1999). The decisions made by practitioners reacting to a perception of threat.The findings from this study. when compared with the literature on sexual boundary violations. Our sample was able to describe experiences of attraction and boundary breaches. In several examples. first. from a sample of participants who had managed to avoid sexual boundary violations. In spite of this. are consistent with literature that suggests that sexual boundary violations may not occur suddenly and that boundary breaches are likely to be the first steps toward sexual boundary violation (Somer and Saadon. 1999: Gorovitz (1982) cited in Sarkar (2004). drawn as they were. none of these accounts could be construed as a description of a sexual boundary violation. thus compounding a perceived change in the balance of power in sessions. and however the participant felt about their actions. The team were left with two conclusions. the difference was that they took these minor breaches seriously as cause for concern and either acted to reinforce therapeutic boundaries or emphasised the need for reflection. These seemed to involve hostility or distancing. and second. Norris et al (2003) and Celenza (2005) suggest that difficulty working with aggression and other negative feelings may contribute to a defensive sexualisation. seem to reflect similar themes. along with self-protection and reduced capacity to attend to the client‟s emotional experience. the actions taken by practitioners in an attempt to avoid sexual boundary violations sometimes resulted in a loss of empathic responding that was potentially problematic in its own right. as recounted by participants.

As there was some indication that anxiety and loss of emotional equilibrium had a part to play in determining the degree of empathic responding and in shaping the practitioner response (cf. each time they enter a therapy session. and one that fits with our own observations of clinician activity. There is possibly a need to reflect on practitioners‟ understanding of empathic responding. Celenza.to avoid experiences of disappointment or hate. 305) writes: “Empathy is a skill… a simultaneous process of feeling resonant with the patient while remaining apart and observing one‟s own reactions. Celenza (1995. 2005) it seems logical that practitioners‟ work might benefit from strategies aimed at reducing uncertainty and fear of exposure. Most felt that sexualising the relationship. There are implications both for training and accrediting organisations. There was some variation as the meaning and severity of the contact became less clear cut. and which emphasises the engagement end of the balance we have noted. it is possible to see once again. Common definitions emphasise the emotional component of the activity.” Using this definition. all gave examples of problematic responses and 75 . when crossing a usual boundary. This dimension makes it impossible to frame ethical guidelines in terms of specific actions. with what we have called the participant/ observer stance. It is this definition that is hard to separate from sympathy. touch and flirtation were unacceptable. It was of interest that constructive responses to threats to boundaries were not restricted to a sub-group of the participants. participants felt that it was important to understand these lapses. and supervision was seen as one resource for this reflection. empathy is understood as an ability to „put oneself into the situation of the other and to feel as they do‟. the motivations of the therapist became crucial. apparently innocuous actions may contain more sexual intent than more obvious ones. For some therapists. Celenza (1995) offers a more complex definition. An initial finding was the consistency of definitions at the extremes of therapeutic activity. There was universal opprobrium in relation to therapist-client sexual activity. the balancing act that clinicians aim to engage in.

There were however. One of these is a difficulty managing the awareness that a colleague‟s practice may be unsound. It did seem that experience played a significant part. with an emphasis on reflection. but their descriptions suggested that they felt less unnerved by them as they occurred. practitioners offered views across the range. may be a protective factor. and some practitioners had moved from more liberal to more conservative positions over time and in response to experiences with clients.found that it often took some time before the experience was understood and processed sufficiently for constructive use in sessions. Some practitioners prefer never to touch. supported by theory for many as it was. 2003 offer a range of arguments about the value and meaning of touch. some areas of uncertainty. the recognition that to report would compromise therapy made the prospect of reporting difficult in the extreme. there was a clear theme concerned with meaning. Furthermore. whatever the profession or modality. Experienced practitioners did not appear to avoid boundary breaches entirely. and having learned from past experiences that they could be remedied. they were more confident to take such incidents routinely for supervision. and of finding supervisors or seeking consultations to make such decisions clearer. This conservative stance. Confidentiality also conflicted with the requirement to report. 1985 and Orbach. Many were comfortable with the responsibility of balancing different and conflicting ethical concerns. In this sample. 1997. Some of the examples given were compounded by the recognition that the evidence on which the colleague‟s conduct was under suspicion was flimsy. touch is a contentious issue. for others it is integral to practice. either as direct confession or in relation to contacts with another professional. Within the literature. often coming from third parties or from intuition. 76 . Under these circumstances. Twemlow. and attention to the meaning of desires to deviate or actual deviations from usual practice. Hetherington. but a tendency for a conservative view was clear. None of the participants proved ignorant of the ethical principles and all recognised the value of core principles. evidence came from therapeutic sessions. 2000a&b: Casement.

1) Accrediting bodies  Accrediting bodies have an important role to play in sustaining individual practitioners‟ links to a community of practice. and perhaps given the degree of anxiety and desire for self-protection felt by practitioners as they struggle through the process of making sense (as in Chapter 4). on the one hand. While it is accepted that this purpose is served both through publications and CPD activities. and challenging the trainee to examine these in context and to question the experience. clinical supervision. There were five key areas of practice identified: practitioners and their work. so that the practitioner was facilitated to think as constructively as s/he is able. again required to be in appropriate balance. others are developed from reflecting on the accounts of experiences in clinical work and supervision. Given that these are based on data from a single study. Some are drawn directly from the views and values of the practitioner accounts. 77 . accrediting bodies.Accounts of supervision demonstrated useful supervision as having two components. When the practitioner had breached a boundary (or the supervisor suspected that this was the case) the supervisor engaged in two activities. the recommendations have been framed as issues for reflection rather than directions. on the other. there may be a need to consider ways of making these palatable and even reassuring to practitioners. thereby ensuring maximum dissemination and ownership through the membership. This process seemed to require as much capacity to respond empathically as the clinical work itself. and training organisations. Recommendations for practice The findings of this study were used to develop recommendations for practice. empathy is crucial. offering practitioners a sense of belonging and identity and supporting professional and ethical standards. normalising the presence of the feelings. employing organisations.

and the anecdotal and clinical literature on the difficulties of reporting therapies (Szecsody. and guide training organisations and practitioners towards best practice. While it is recognised that there may be several pathways to the development of this capability. but often remediable and sometimes therapeutically useful. It would be helpful for there to be adequate supportive as well as investigatory structures within each organisation. not only for the practitioner under investigation. but for colleagues and others in the profession. and sometimes misunderstandings. The practitioner is likely to be vulnerable.  The therapeutic management of boundaries and effective supervision require a capability in therapist or supervisor to think under pressure. and to make the outcome of such considerations available to members. there may be a need to support further research in this area. do no harm. and at worst. Some participants highlighted the value of personal therapy. accrediting bodies might helpfully consider the role of experiences such as personal therapy and reflective practice. it is important to remember that allegations are the culmination of a complex series of events. others commended active skills acquisition during training sessions. whether innocent or not. Given the relatively sparse and weak evidence base on the benefits of personal therapy. and the procedures bring additional anxieties. It may be important for accrediting organisations to review their stance on the acceptability of personal and other relationships with ex-clients. Whilst accrediting bodies have a duty to investigate alleged sexual boundary violations.  Given the findings of this report. there is a need for organisations to take into account the risks inherent in working in this domain. in spite of therapists‟ own beliefs in its efficacy. It may be useful in the mean time to recommend pathways for personal development to promote alternatives or 78 . 1999). which suggest that participants understand boundary breaches as regrettable.

 Given the uncertainty expressed by participants about conditions and processes for managing third party reporting. While the successful management of boundaries under pressure is perhaps best understood as a capability.  Practitioners who transgress sexual boundary violations. may be required to undertake a process of rehabilitation or disqualified from practice. and this would be a valuable addition. 79 . it may be important to develop guidelines that outline the circumstances under which such reporting should take place. programme teams might usefully review ways of increasing trainees‟ skills in making use of these principles in clinical practice and in linking their own feelings and anxieties to their responses when faced with ethical dilemmas in clinical settings. the type and strength of evidence required. and are then disciplined. the model and themes described in Chapters 4 and 5 may contribute to the future evaluation of rehabilitation. especially whether regular clinical supervision is mandatory. 2) Training organisations  Training on ethical guidelines is already included in courses for accredited psychological therapists.  Accrediting organisations may need to consider quality assurance for supervision. and the safeguards in place for protecting and supporting all concerned. There is little research evidence about the success of rehabilitation.supplements to personal therapy for those practitioners who are not required to undertake personal therapy during training. what training and supervision supervisors should undertake. Guidelines should include information about the sources of information and the nature of the relationship with the client and colleague involved in a sexual boundary violation. and inform and support practitioners and supervisors. and how those engaged in supervision might evaluate its value for clinical practice.

Students who do not learn to work through this process may need remedial skills training or supervision. and the systems for supporting staff in the acquisition and maintenance of this level of expertise. It was interesting to note. they may need to review the demand for practitioners accredited through therapy organisations. so that trainees understand that this is normal and the issue does not become „the elephant in the room‟. humane and just procedures in place for investigating alleged boundary violations. and to assist staff with less training and experience in doing so. their training had taken years. 80 . however. they had self-funded part or all of training. 3) Employing organisations  Within our sample. therapy and supervision. where support to undertake accredited trainings may be limited. something that provokes so much anxiety or shame that discussion becomes impossible. supported and supervised in their clinical work. This might also include discussion of differences in assumptions deriving from cultural expectations. It seems beneficial to address issues of sexual attraction in training. or rejection of the existing ethical standards. It would be beneficial to consult widely so that staff are included in the development of policy in relation to clinical practice and can develop a sense of ownership of policy. for example. these participants form a sample unusual in comparison to the majority of public sector staff.  Employing organisations might review policies and procedures to ensure that staff are well informed about ethical and organisational expectations of boundary keeping. In this sense.  Training organisations may consider adopting the process model described in Chapter 4 into a template for evaluation of clinical skills development. the varied pathways to accredited status and work conditions described by participants. For many. and that there are clear. there was no resistance to the concept of accreditation. If public sector organisations require staff with the capabilities to manage boundaries under pressure. about touch and self-disclosure.

and keeping clinicians involved with service development may serve a protective function. 4) Clinical supervision  Given the number of tasks and complexity described in good supervision. it may be necessary to consider the balance of a practitioner‟s caseload.  In our sample. and those staff who feel demoralised. supervisors might consider how to gain competence in and maintain the quality of the supervision they provide. In parallel with practitioner values. an understanding of the way the practitioner manages emotional needs. This might involve training and supervision of supervisory practice.  A formulation of the practitioner and their learning needs and vulnerabilities might be a helpful aid for noticing difficulties early. may be more vulnerable to boundary breaches. change management is likely to be an important feature for maintaining clinical standards. Practitioners may become more vulnerable when feeling disempowered or stressed. Line managers in particular may be well placed to help staff manage this vulnerability more constructively. For example. such as needs for intimacy. including where the boundaries lay. Staff moving into new work settings. so that no one professional group or individual is always required to take on the clients that practitioners find difficult or draining to see. there were instances of difficulty in supervision attributed to different views on boundaries. When potential 81 . the supervisor would do well to develop a clear understanding of the rationale for the boundaries required between supervisor and supervisee. and find them more personally satisfying. In particular. anxious about disclosing them.  Morale and self-esteem may have a part to play in the practitioner‟s capacity to withstand pressure on therapeutic boundaries: it would be advisable for managers of services to consider the resources and organisational culture necessary for these to be maintained. success or recognition may be useful.

one who normalised.  It seemed that our participants valued the opportunity to discuss embarrassing or worrying experiences in supervision over time. recognising that the practitioner may feel the need to minimise. these may raise anxieties in supervisees. embarrassment and shame. The concept of a tension between reassurance and normalising on the one hand and suspicion and challenge on the other. who contrasted two supervisors. disguise or avoid difficulties. This was highlighted by one participant in our sample. may be helpful in guiding the supervisor through the process of inviting disclosure and exploration. supervisors need to be proactive in addressing the supervisee‟s anxiety. would be explicit discussion when agreeing to take on a new supervisee. while the other challenged to a degree that felt pathologising. and make decisions on the basis of their assessment.disagreements about the significance of actions arise during discussion of clinical work. Formal contracting may helpfully include these areas. One possible strategy for supervisors who are concerned to facilitate discussions of clinical work in which anxiety and intense emotional states arise. This discussion might usefully acknowledge the possibility that sexual attraction is one of the experiences that are likely to arise in therapy and that the supervisor aims to offer a safe setting in which to explore the meaning of such events. the supervisor may need to estimate whether a successful supervisory relationship will develop. One example from our sample that seemed particularly anxiety-provoking to practitioners was the pairing of a supervisor who believed that boundary breaches such as touch were problematic and the practitioner who had a more liberal interpretation and felt undermined by the supervisor‟s approach.  Whether or not there are differences in choice of therapy framework. neither was experienced as able to combine the two and help the practitioner manage such situations effectively. 82 . Under such circumstances.

deviation from which would indicate a boundary breach. and a default position. practitioners need to seek and actively develop an understanding of this prohibition. thereby initiating a process of reflection and if necessary. recognise their own attitudes towards these and develop strategies for managing them.  Self. practitioners need to develop a sense of the degree to which they comply with and work within appropriate boundaries. Practitioners successful in managing threats to boundaries seemed to have one or more of these characteristics: a satisfying life and good relationships. Single status and marital dissatisfaction were mentioned specifically.  Once their values are relatively clear. 5) Practitioners and their work  Given the universal recognition that sexual relationships between therapists and their clients are harmful. of the circumstances (if any) in which they are prepared to be flexible. often mentioned in ethical guidelines. setting and touch. a capacity to reflect on their own emotional needs and the ability to recognise their own vulnerabilities. life circumstances sometimes contributed. Furthermore. Supervisors might bear in mind. and a rationale for adhering to it based on values and benefits rather than threat alone. including time. Supervisors may need to consider how to best offer advice on the management of personal distress. These contributed to an illusion that client and practitioner needs might be satisfied by breaching boundaries. supervision. Some clients seemed able to affect the practitioner‟s behaviour. not the personal circumstances of the supervisee. but the supervisee‟s experience of those personal circumstances and the meaning attributed to them. Some of our participants noted periods of increased vulnerability. practitioners need to develop an understanding of the function of other boundaries. as part of their analysis of the total situation. and a 83 .care and a capacity to reflect on one‟s own activity are important considerations.

This makes it imperative that they take responsibility for discussing boundary breaches in supervision. therapeutic framework and styles of practitioner and supervisor may affect the use it is possible to make of supervision.  Clinicians. along with their trainers and supervisors. whatever the reason. and to review regularly the extent to which supervision continues to offer a secure and exploratory experience. it is the practitioner‟s responsibility to offer these for discussion in supervision. taking further steps to promote good practice. mode of delivery. When the practitioner finds this discussion is compromised. especially training or supervision. it may be helpful to discuss the supervisor‟s approach to the issues at the start. it may be advisable to consider requesting a consultation or finding an alternative route for reflection rather than ignoring even a minor boundary breach.preparedness to admit the need for measures to maintain their fitness for practice.  Given that practitioners recognise the possibility and desirability of using the understanding of minor boundary beaches for therapeutic benefit.  Clinicians are advised to consider their own need for supervision. this may include dreams and fantasies as well as actions. Committing to a supervisor is therefore an important decision. practitioners need to feel confident that discussing boundary issues. may find the model developed in Chapter 4 and the typology in Chapter 5 useful for reviewing how they are managing 84 . however embarrassing. and that such events may have symbolic meaning that develops such understanding. whether in terms of adopting personal strategies or taking major steps such as entering therapy. or changing some element of personal life or practice. once qualified.  Practitioners are responsible. A match between the values. The requirements of a practitioner may change over the course of time. especially sexual boundary issues. The quality of the supervision itself seemed to be important. will be met with a response that enables the practitioner to benefit from supervision. for their professional conduct.

it allowed the generation of rich data. sex. their understanding of these events and their reactions to these experiences. working arrangements and environments. and location. The sample comprises practitioners varied in terms of therapeutic orientations. years in practice.clinical situations where is a threat to the boundaries. although there is some. Strengths and limitations In this section. sexual orientation. including detailed accounts of a range of clinicians‟ struggles in the face of sexual attraction within therapy. There is limited cultural and racial diversity. through difficulties in working with attraction. The adoption of several strategies for recruitment not only enabled clinicians with an interest in the topic area to come forward. training. there is a brief outline of the team‟s assessment of strengths and limitations of the study. but who might not have felt sufficiently strongly to volunteer themselves without the request to do so. however. and required the team to develop the findings in language that would be meaningful for practitioners working with different models. including boundary management and therapeutic strategies. and the research team were able to identify meaningful themes and develop models demonstrating the complex processes and relationships implicit in the interviews. in order to provide the reader with some of the information required for deciding on the merit of the findings and recommendations. The study design was innovative. This sub-sample may increase the degree to which the findings can be seen as representative of the body of clinicians. age. The data was apposite to the research questions. 85 . client groups. this may reflect. but also allowed the inclusion of practitioners who had experience and expertise in the topic area. types of experience. This variety within the sample facilitated the collection of a range of views and responses to the research topic. the characteristics of the population of practitioners.

records of debriefing meetings. An initial experiment with computer-assisted analysis only confirmed the need for manual analysis. The range of backgrounds of the team acted to keep the analysis grounded in the data. This allowed the analysis to incorporate the interviewer‟s reactions and understanding into an interpretative account of the data. this meant that some areas are covered more intensively in a subset of the interviews. more evenly balanced in terms of gender. Given the analytic strategy. the team prioritised the appearance of a theme over the extent to which this theme was present in the sample as a whole. and the period of data analysis became extended and pressured. the complexity of the analysis required time. there was variability in interview style and focus. 86 . as we experienced the full extent of challenge and debate necessary for consensus. The differences between the team members shaped the collection of data and analysis. Conversely. All researchers collected data. From this sample. it is possible to draw conclusions salient to the practice of the clinician who is drawn into sexual boundary violations because of personal difficulties or skills deficits (the „troubled clinician‟) but the findings are unlikely to be as relevant for the entrenched serial transgressor. The number of interviews was large for a project of this type and duration. generated through consideration of memos. it would be advisable to consider the characteristics of this selected group. the sample size is small and in order to generalise from the sample to the population of practitioners. and had possibly experienced longer and more intensive training than the average practitioner. this need not be considered a limitation. The final sample was older. The analytic strategy incorporated additional data. and discussion between analysts. it clarified each individual‟s „taken for granted‟ assumptions to a greater degree than is perhaps usual.The size of the sample had both benefits and drawbacks.

There might be useful conclusions to be drawn from exploring such accounts for thematic differences. These did not seem alien to audiences. regardless of the sex of the participant. there may be value in exploring the relevance and influence of cultural factors. and there were examples of attraction to clients in all accounts. This review. as the sample is small and selected. While there was a comprehensive and valuable report covering the research evidence published only recently. including a workshop in the BACP Annual conference (2009). When designing the study. and of how applicable they might be to therapy and counselling generally. in order to preserve a positive self-image or selfesteem. In line with Twemlow‟s (1997) recommendations. issues of sexuality and management of feelings of attraction to clients were common to both 87 . the team were concerned that accounts given by practitioners who had been engaged in sexual boundary violations might be different. Future research There are similarities between the findings of this study and the reflective literature. However. These findings may have implications for developing and assessing procedures for rehabilitation. it is noteworthy that one of the consistent risk factors is being male. the findings have been offered to a small number of individuals and groups.Prior to the report. which strengthens our conclusions and recommendations. for example. and the subsequent analyses of the literature it generated. has contributed to the discussion of the findings. there might be different attributions made. the team commissioned a more specific systematic literature review. Our sample was evenly divided between men and women. it is likely that conducting similar studies would give some indication of the extent to which the findings from this study are representative of practitioners as a whole. In reviewing the evidence base.

male and female therapists. Furthermore, both male and female therapists gave examples of attraction to both male and female clients; and the practitioner might be either homosexual or heterosexual. What became clear was that issues of attraction and sexual elements in the experience of relationships within therapy were present for therapists regardless of the sex of therapist or client. One issue raised by several participants was the tendency to understand a parental, and in particular, a maternal response to clients as defensive or selfprotective. Given that defences offer indirect rather than direct expression or avoidance of feelings, it is possible that this particular defence, with the emphasis on nurturance, may become part of a „slippery slope‟ which if not remedied, may lead to boundary breaches. In particular, physical contact, for example, the hug intended to comfort or reassure, may be considered relatively unproblematic when experienced in conjunction with maternal feelings. There are also indications in the literature of more complex relationships between feelings of attraction and sex in other papers. For example, Pope, Keith-Spiegel and Tabachnick (1986) noted differential response rates when surveying 1000 psychologists, with men being more likely to respond than women (68% compared with 49%). Men reported being attracted more by physical characteristics, and women by success. They also commented on a recent increase in malpractice suits against women therapists in the US which they thought might reflect an increased preparedness to accept that women may also transgress. If female therapists are at risk, it behoves future research to focus on the complexities of the dynamics in therapeutic relationships for therapists of both sexes. The findings from the literature on client experiences of TCS and from this study might usefully be extended or qualified through the study of boundary breaches in detail, through direct observation or analysis of other data sources,, such as client records. It may useful to identify the most common errors and the most easily used strategies for success; the findings may have a role in enabling staff from training programmes to support the development of positive strategies.

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It may be useful to explore the subjective experiences of clinicians undergoing training in the management of boundaries and in managing ethical dilemmas, to facilitate more successful training, and to identify indicators of successful internalisation of an ethical stance, over and above compliance with the rules. Given the importance attached to supervision as an aid to the successful management of boundaries, there may be value in exploring the factors that contribute to an effective supervision process. Given the possibility of using therapy and supervision in rehabilitation, it may be worth testing the utility of the model generated in Chapter 4 and the typology of reactions to threat identified in Chapter 5 in evaluations of the rehabilitation process.

Conclusions The majority of practitioners in the sample were aware of the universality of sexual feelings and the likelihood that attraction would occur during some therapeutic contacts; this was not seen as problematic or shameful, and the emphasis was on the meaning of and response to such feelings. The process identified for recognising signals that might lead to sexual boundary violations and then resolving them is described in Chapter 4. Signals included anxiety and unease; sexual attraction and sexual conduct outside the normal range of the practitioner, e.g. flirting; minor boundary breaches that indicated pressure on the therapy boundaries; and the need for increased understanding of the interpersonal element of the therapy session. Practitioners used a number of resources; some mentioned training and clear ethical guidelines; others had developed frameworks for making sense of sexual attraction and sexualised behaviours. In particular, some therapists understood sexualised relationships as protective strategies. Whether experienced by client or practitioner, sexual feelings were often seen as masking or communicating about other conflicts or needs. These included attempts to avoid loss, separation, helplessness or abandonment; reluctance to face the client‟s disappointment or anger, or strategies employed to manage self-esteem

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and self-worth. These frameworks facilitated the endeavour to make therapeutic use of boundary breaches to the benefit of the client. Good supervision was seen as crucial for this process; the ideal was to develop an internal supervisor who would assist the practitioner make more effective interventions and protect therapy through management of the boundaries. Experienced practitioners described a process of working through clinical situations that required them to process their experience and reflect on it to the client‟s benefit. The participant/ observer stance identified as essential for this process to work well is compatible with Celenza‟s (1995) definition of empathy, which also points up an experiential and a reflective element. Even when such frameworks and supports were unavailable, these practitioners were able to avoid sexual boundary violations. A typology of four reactions to the clinicians‟ perception of a threat to the boundaries involving attraction was apparent in the more problematic examples. These sometimes served to prevent development of a SBV, through for example, a return to ethical guidelines; there were examples of explicitly reaffirming boundaries. There were unfortunate consequences for clients or the therapy process, however, in some examples of this; some practitioners regretted the interventions they had made and felt that they had learned from reflecting on their experience and conduct. In other examples, the experience of providing the therapy was costly and perhaps risky, as the practitioner struggled to work and contain their own feelings of neediness and distress during the period of attraction. In conclusion, clinicians experience a number of issues to balance to keep and tensions to manage. When taken to supervision, this is recreated, and the supervisor has a role in helping the therapist contain anxiety and understand the significance of their experience. While personal characteristics and vulnerabilities may play a significant part in sexual boundary violations, something that this study did not set out to answer, these participants found a variety of ways, more or less successful, through the clinical situations they faced. Their accounts stress the value of supervision and training in the management of

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the ethical dilemmas that boundary breaches give rise to. and of theoretical frameworks that allow an understanding of what is not explicit in therapeutic sessions. 91 .

nurses. Will use papers where majority of therapists specified are described in the current review‟s research question. Inclusion Criteria Published work Language of study Only papers in English. psychotherapists. considered.) Inability to read the content of papers in language other than English. clinical psychologists. APA published 2002. Current review aims to focus on specific practitioners: Counsellors. Quality control of using peer reviewed studies (Number of dissertations /conference proceedings (2). or in English translation.Appendix 1 Systematic Review: (a) Exclusion and inclusion criteria Table 1: Exclusion and inclusion criteria for literature search Exclusion Criteria Timeframe 1997 . (Only one paper .in German . GPs. The last BACP guidelines were published April 2007. Type of practitioner Supervisor-supervisee relationships Current review concerned with therapist-client relationships. Supervisor-supervisee considered a sufficiently distinct context and so is omitted from the current review. 92 .) Exclude papers concerning other areas of sexual boundary violations such as legislation as beyond scope of current study. Rationale Unpublished research will not be included as is not peer reviewed. Rationale The ethics and guidelines are updated regularly. Scoping search found many studies focussing on other types of healthcare professionals: physicians.2008 Narrow search criteria to include only studies from the last 10 years to reflect evolving ethical issues and published guidelines. Indicators leading to sexual boundary violations Select papers with main focus as indicators and prevention of boundary violations.was found that had no English translation. book chapters (4) reported but not reviewed.

nursing. none relevant 22 Reviewed all. books. drugs Medical students. sexual addiction. sexual abuse (non therapeutic situations). legal papers. physicians Psychiatrists. social workers. books. medical students. physicians Replicated from previous search (7). prison violence. dissertation papers. general medicine. dissertations Books. trainee/client relations. none relevant 93 Reviewed all Books. general sexual behaviour studies. supervisors/supervisees. sexual orientation. clergy. books Legislative reviews. Russian. HIV. book reviews. nursing homes (7) 1 0 0 1 Total number of original relevant papers (and papers found in previous search) PSYCINFO 11 (7) 93 .(b) Search strategy (includes empirical and reflective papers) Table 2: Search criteria used for PSYCINFO Search terms Tota l no Exclusion Number of criteria papers 1997reviewed 2008 615 439 Reviewed all Reasons not relevant/Excluded from SSR Releva nt papers 9 1 Sexual boundary violations 2 Therapist sexual misconduct 3 Professional client sexual relations 4 Professionalpatient relations 5 Professional misconduct 6 Patient abuse 545 303 Reviewed all 657 383 Reviewed all 56 36 187 40 Reviewed all.

German. brain injury Replicated from previous search (4). German. police misconduct Social work. suicide. medical ethics Total number of original relevant papers (and papers found in previous search) Web of Science 5 0 1(4) (1) 0 0 179 0 6 (5) 94 . medical students Medical illness.Table 3: Search criteria used for Web of Science Search terms Total no Exclusion criteria 1997–2008 Conference proceedings Number of papers reviewed Reasons not relevant/Excluded from SSR Relevant papers 1 Sexual boundary violations 2 Professionalpatient relations 3 Therapist misconduct 111 61 Reviewed all 72 Reviewed all 25 Reviewed all 94 47 4 Precursors misconduct 5 Indicators misconduct 6 Professional client sexual relations 7 Practitioner ethics 1 7 3 1 Reviewed all 7 Reviewed all 3 Reviewed all 148 Reviewed all Boundary violations of physicians. victimisation of women Issues of participant consent. medicine. student nursing studies. substance abuse. Hippocratic Oath. legislation. legal based papers. hospital patient experiences. doctor-patient conflict. non sexual boundary violations Replicated from previous search (1) Prison behaviour.

traffic violations. condom use Informed consent. nursing. patient confidentiality. scientific/research misconduct Obstetricians & Gynaecologists. trainees. physician-client relations. sexual health. of criteria papers 1997– reviewed 2008 531 380 Reviewed as far as 250 684 Reviewed as far as 300 Reasons not relevant/Excluded from SSR Relevant papers 1 Sexual boundary violations 2 Practitioner misconduct 1079 3 Sexual misconduct 1128 710 Reviewed as far as 300 4 Professional client sexual relations 5 Professionalpatient relations 593 376 Reviewed as far as 300 149 95 Reviewed all. none relevant Legal. psychiatrists. foster care Legal concerns for adults with LD 0 0 0 0 0 61 6 1 0 Total number of original relevant papers Social Care Online 0 95 . sexual health. medical practitioners not relevant to current SSR. gender. victimisation of „whistle blowers‟ Teacher-student boundary violations. sexually transmitted infections. learning disabilities. clergy. social workers. social workers. sexuality. psychiatrists. GP misconduct. legal. medical students Total number of original relevant papers (and papers found in previous search) MEDLINE 4 (2) (3) 1 0 5 (5) Table 5: Search criteria used for Social Care Online Search terms Tota l no Exclusion No. sexual behaviour. previously found in other databases (3). medical based lit Previously found in other databases (2). of criteria papers 1997– reviewed 2008 1 1 Reviewed all abstracts 8 5 Reviewed all abstracts 3 3 Reviewed all abstracts 0 0 47 Reviewed all abstracts 1 Reviewed all abstracts Reasons not relevant/Excluded from SSR Relevan t papers 1 2 3 4 5 Boundary violations Professional misconduct Sexual misconduct Therapist misconduct Sexual abuse and ethics Vulnerable adults and sexual abuse Treatment of sexually abused children Social workers. social workers Clergy.Table 4: Search criteria used for MEDLINE Search terms Total no Exclusion No. scientific misconduct Nurse-client.

(2000) Somer & Nachmani (2005) Somer & Saadon (1999) Source of papers Web of MEDLINE Social Care Science Online CHRE review references X X X X X X X X X 0 5 Papers from review = 5 X X 3 2 1 Total original papers from online databases = 1 96 .(c) Effectiveness of search: empirical studies (reflective papers excluded from table) Table 6: Summary of effectiveness of each database and hand searching Author (date) PSYCINFO Ben-Ari & Somer (2004) Celenza & Hilsenroth (1997) Celenza (1998) Moggi et al.

well matched control group.(d) Summary of empirical papers Table 7: Summary of the empirical papers Research er (Date) Moggi et al. 43 controls Focus on client characteristics Paper finds that attention should be directed to identify combinations of factors rather than focusing on individuals‟ determinants. self selected but information „rich‟. These include : characteristics of therapists/clients & the settings & processes in therapist-patient relationship that may lead to SBV in psychotherapy Ben-Ari & Somer (2004) Clinical Psychology & Psychother apy Israel Qualitati ve Primary data from semistructured interviews 14 women patients engaged in TCS To help participants through a personal transformation to confront painful TCS experience Focus on client characteristics Emotionally deprived. lonely. selection bias due to participant motivation Small sample size. difficulties with relationships (especially fathers & male partners). participants missing data excluded from analysis. Processes are more subtle & need research Methodologic al quality Good sample size due to anonymity of questionnaire. previous abuse (refer to 97 . in crisis. large n means high generalisability. low self confidence. problem saturated. reliable (high Cronbach‟s α) & valid questionnaire. Author is trained & experienced Clinical Psychology & Psychother apy Survey Primary data from research questionnaire 100 women: 57 sexually abused by psychothera pist. low self- Awareness of patients at risk: new female patients. (2000) Journal Count ry Switze rland Design Data/ Evidence Sample Key aims of paper To examine patient sexual abuse risk factors & assess psychological consequences Indicators identified Implications for findings Neither personality factors nor circumstances during psychotherapy are directly predictive of sexual abuse. no control group.

& postemotional well being. Client perceptions (romance/abuse) of TCS affect pre-. „Romance group‟ emotional well being better at all time points (before. 98 .(from victim to survivor) esteem. peri. after TCS) than those in „abuse‟ group experienced female therapists). „Romance group‟ buffered against negative effects during relationship but suffered severe deterioration in emotional well being after sexual contact ceased. lacking in self confidence Somer & Nachman i (2005) Sexual Abuse: A Journal of Research & Treatment Israel Quantita tive Qualitati ve Primary data from questionnaire completed via phone (n=11) or in person (n=13) 23 female patients & 1 male patient engaged in TCS To investigate experiences of psychotherapy clients emotionally & sexually exploited by therapist Focus on client characteristics All felt exploited & betrayed by therapist. during. & psychological symptoms of TCS-Romance & TCS-Abuse clinician. defence mechanisms. participant selfselection. problems with retrospective nature of design (8years past so participants may reformulate memory reconstructions & report inaccurate perceptions & feelings about experience). More media coverage to empower victims to report abuse Future research to compare abuse histories. study involved therapists other than those specified in research question Small sample size.

problems of retrospective design as average of 7.Somer & Saadon (1999) Professional Psychology: Research & Practice Israel Qualitative Primary data Quantitative from research questionnaire 27 women patients engaged in TCS. conduct therapy in setting shared with others. middle-aged. Recommendations to prevent SBV: consider small increments of actions leading toward erotic intimacy.7 years past since TCS so memories may have been effected by factors such as how they dealt with feelings towards therapist. as children. special care to maintain clear boundaries especially if client was victim of child abuse. problems in previous interpersonal relationships Recommended that regulation boards develop strategies to address more mature professionals at risk of personal crisis. male psychologist. working alone in private practice. Mental health professionals need routine screenings for childhood trauma Limitations of small sample size. depression. 26 control women patients attending Israel Institute for Treatment & Study of Stress not engaged in TCS To improve effectiveness of therapists through increasing understanding of factors that contribute to SBV Focus on therapist characteristics Profile of therapist at risk for SBV: reputable. mainstream. or burnout. subsequent unrelated negative life events occurring after experiences may have been attributed to negative outcomes from TCS 99 . mandatory consultation & peer supervision (requirements for license renewal) Focus on client characteristics Distinct risk client group who have been traumatised in their past. exposed to emotional neglect/sexual abuse. however control group well matched.

unresolved anger towards authority figures. defensive transformation of countertransference Focus on therapist 20 mental Identifying health characteristics characteristics professionals of Profile comprising several engaged in transgressing related personality sexualized therapists & characteristics & dual rehabilitation vulnerabilities. 100 . sexualisation of pre-genital needs. Small sample. 17 mental health therapists sexually involved with patient Explores characteristics & predisposing factors in therapists who transgress SBV Need for less punitive atmosphere within therapy profession so therapists feel free to seek help before SBV occur Awareness of personal vulnerabilities within therapists. unmatched control sample of 700. those that identified by others or by themselves as sexual boundary violators.e. covert & sanctioned boundary transgression by a parental figure. multiple and rich data sources. especially with regards to future training Small sample. comprised individuals referred from a range of sources i. restricted awareness of fantasy.Celenza (1998) Psychoanalytic USA Psychology Qualitative Data from Quantitative consultations. involved therapists other than those specified in research question. treatments Celenza & Bulletin of the Hilsenroth Menniger (1997) Clinic USA Qualitative Primary data Quantitative assessed by Rorschach protocols Focus on therapist characteristics Longstanding & unresolved problems with self esteem. supervisions. relationships potential Significantly higher levels of distress specific to interpersonal longing & helplessness. intolerance of negative transference.

please let us know and this can be arranged. we will respect your wish to stop at any point. We wish to explore with practitioners examples of situations that have been experienced as sufficiently problematic to require thought and psychological work. It provides an overview of the study and of what would happen if you decided to participate. Leeds Institute of Health Sciences. Institute of Psychological Sciences. 101 . The team members are Mary Godfrey and Carol Martin. If for any reason. and to contribute to academic and professional debate through further publications.Appendix 2 UNIVERSITY OF LEEDS Research into practitioners’ experiences of successfully managing the risk of sexual boundary violations with clients Information sheet This Information Sheet is designed to provide you with information about this study so that you can decide whether you would like to take part. What happens if I decide to take part? If you decide to take part we will arrange an interview with you at a location convenient to you at a mutually convenient time. What contribution will the research make? The findings will be developed into a report for the BACP and guidelines for practitioner members. What is the timescale for the research? The final report should be developed during the summer of 2009 for sending to the BACP in September 2009. The interview will take about an hour to an hour and a half. Our particular focus is on developing understanding of the resources. If you agree. and notes taken. the interview will be audio recorded. If you decide to take part you are still free to withdraw at any time and without giving a reason. you feel uncomfortable during the interview. We are seeking to interview practitioners about experiences of sexual attraction to clients in therapy and in related activities such as supervision. It is obviously up to you to decide whether or not to take part. The aim is to support practitioners to manage emotionally demanding therapeutic situations within the professional boundaries they adopt as part of their professional practice. and Bonnie Meekums. If you would prefer to be interviewed by a male interviewer. The purpose of the study is to investigate how practitioners understand sexual boundary issues in their therapeutic encounters and how they manage the boundaries when they experience feelings of attraction towards clients. strengths and strategies that practitioners draw upon to manage threats of sexual boundary violations and the factors that might enhance or compromise the use of these. If you do decide to take part you will be asked to sign a consent form. but not to the extent that the accepted sexual boundaries have been breached. University of Leeds. The purpose of this study and the research team This study has been commissioned from the University of Leeds by the British Association of Counselling and Psychotherapy (BACP). Anna Madill. We are a team of researchers based at Leeds University with experience of practice or research into psychological therapies and counselling. School of Healthcare.

the interviewer will discuss whether it is appropriate to continue and possible alternative arrangements if the interview needs to be drawn to a close. 101. If you show signs of distress. University of Leeds.What will happen to the information I provide? No identifying details will be attached to transcripts. What are the benefits and risks of taking part? As with similar studies that are concerned with emotional and sensitive issues. anonymised and password protected. Leeds Institute of Health Sciences. Thank you for taking the time to read this leaflet. University of Leeds. there is the potential for distress.com/9rr8v2). the interviewer will not ask you to provide information on actual breaches of sexual boundaries. the focus of this study is on successful management of therapeutic boundaries. particularly if there is potential future or actual harm to others. notifying you of your right to withdraw and of the protection of your anonymity. What if I have a complaint about the study? If you have any concerns about your involvement in this research you should. Clarendon Road. In such studies. if the interviewer feels that the interview may be going that way. so that you have the opportunity to avoid disclosing details of sexual boundary violations that might require reporting to a professional body. however. it has often been noted that participants state that the opportunity to reflect in confidence and to contribute to potential future benefits is worthwhile and of value to them. 102 . All data will be kept secure. Personal details such as names and places will be kept separate from transcripts so that the interview content will not be identifiable with individuals. raise them with the researcher conducting the interview or with whom you have spoken or e-mailed. If you wish to make a complaint you can do so by contacting Mary Godfrey. If you are interested in the study and have any further questions. and will be destroyed after completion of the study and publications. their codes of ethics require that a serious breach of boundaries. they will let you know. What will I be asked about? The researchers are aware that sexual boundary violations with clients contravene the codes of ethics and practice to which practitioners adhere. is reported. However. in the first instance. you will find further information on the LIHS website (http://tinyurl. Further. and that for some of the team. Leeds LS2 9LJ. Who has given permission for the study to go ahead? This research is subject to ethical guidelines as set out by the BACP and the British Psychological Society and has been approved by the Ethics Committee within the Leeds Institute of Health Sciences. These guidelines include principles such as obtaining your informed consent before conducting an interview.

to end the interview and to withdraw from the study at any time without having to give a reason I agree to the interview being audio-recorded I grant permission for extracts from the interview to be used in reports of the research on the understanding that my anonymity will be maintained I understand that should I reveal information that describes a breach in professional boundaries that would normally require investigation. I have read the participant information sheet and have had the opportunity to ask questions and to discuss the study I have received satisfactory answers to all of my questions and have received enough information about the study I understand that I am free to choose not to answer a question. he or she will inform me that there will be a discussion with the team and of the decision to report I agree to take part in this study Participant signature Date Name of participant Researcher signature Date Name of researcher Thank you for agreeing to take part in this study. that the interviewer may be obliged to report this to my professional organisation.Appendix 3 UNIVERSITY OF LEEDS Consent Form Study title: Research into practitioners’ experiences of successfully managing the risk of sexual boundary violations with clients The purpose of this form is to make sure that you are happy to take part in the research and that you know what is involved. 103 . Please confirm each statement by putting your initials in the associated box.

and are interested in finding out what helps them keep within accepted ethical and professional boundaries.ac.leeds.Appendix 4 Have you experience of successfully managing sexual attraction to your clients or supervisees? We hope to interview a group of practitioners who have learned skills and strategies from their practice. please look at our webpage: http://www.html Or you can contact us by telephone: 0113 3432732 104 . If you are interested in taking part. This is a research study carried out from the University of Leeds.uk/hsphr/psychiatry/courses/dclin/staff_research_projects. or would like to know more about the study. commissioned by the British Association of Counselling and Psychotherapy.

Appendix 5
Interview topic guide Stage 1: Introduction and basic information Thank you for agreeing to meet me today and offering to take part in this study. I would like first to outline the study and go through the information sheet with you, so that you are able to decide whether you wish to proceed further. There are no right or wrong answers to anything I ask you. [Consent form; Basic information- might be collected here or at the end of the interview- to include training, nature of client work undertaken, years of experience, current roles] Stage 2: main interview 1. I wonder if we might start with your own interest in this area: I wonder if you would tell me what led you to come forward for this study? 2. What is your understanding of a sexual boundary and of sexual boundary violations in clinical practice? Normal or usual limits on touch and sexual behaviours? Rationale for having an embargo on sexual contact with clients? Rationale for permitting or using physical touch, flirtation or similar behaviours in therapy with clients or ex-clients? What makes for a risky situation? What predictable features might there be that contribute to a risky situation? 3. We know that you agreed to take part because of personal experiences of having successfully managed feelings of sexual attraction to clients. Please would you tell me about one? 3a. What did you first notice? Please could you say something about your reactions? What sense did you make of this? What were your concerns/anxieties at this stage? What was your therapeutic work with your client like at this point? 3b. What quality did the feelings have, at first and as they developed over time? What feelings did you have? How did you understand these feelings? I wonder if you would say something about how these feelings compared to feelings you had or have for other people to whom you have felt sexually attracted (similarities/ differences in quality)? Please would you say something about how these affected you personally? And in your work? 3c. What else was going on in your life at this time? When did this happen? (sources of stress/anxiety; challenges to self esteem; disturbance in relationships; transitions) 3d. What did you do when you first noticed your feelings of sexual attraction? N.B. These might include: Internal management and self-control Changed understanding and reformulation

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Changes to the therapeutic setting or to practitioner behaviour Help seeking Making changes to conditions external to the therapy 3e. How did the situation develop? What was it like for you when working with this client? What did the client know and think was happening? What difference did it make to your therapy work? What difference did it make to other parts of your life? 3f. I would like to know how you managed this part of the experience. What did you contemplate doing that you would not normally do? What did you actually do? What did you find yourself not doing that you might normally have done? 3g. What use did you make of your professional and ethical codes? I wonder how you felt about the limits on sexual relationships with clients set by your codes at this time? What was your understanding of these limits at this point? What was the line you contemplated crossing? (i.e., what would have constituted a sexual boundary violation?) And what response you felt you might have from others to your situation? And how were these understandings different to the time before, and then after this situation? 3h. How did the situation resolve? What made the difference? What sense does this event have for you now? What did you learn from this experience for your therapy work and for the benefit of future clients? Or about yourself and your own life? How close were you to crossing the boundary at any time? I wonder what you feel now that this situation is over. General prompts: What did you do next? I wonder what you felt at this point? What sense were you making of things at this time? Would you say more about [thoughts, feelings, views, situation, behaviour, etc.]? 3i. I wonder whether you have further examples? If so, revisit the earlier questions and repeat for each example. 4. Overall, what do you feel makes it possible for you to work successfully when there are potential threats to therapeutic boundaries, and to work constructively with sexual attraction in therapy? What would you have done differently if you knew then what you know now? What benefits are there for clients when you as a therapist feel some attraction? How significant are the risks for clients; for therapists- and how has this changed for you with increased experience? What might have helped you seek help or stopped you seeking help? What more do you feel the professions could offer which would help practitioners facing the issue of sexual attraction to clients? What would you advise other practitioners facing this situation?

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Stage 3: Ending 5. Is there anything further that you feel you have not yet been able to tell me and that you think would be useful? Thank you for taking part. [Arrange second meeting if needed; copy of findings; expenses; basic information if still to be collected; offer that if they have more to say afterwards they can have a follow up phone conversation and give a means of contact.]

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Appendix 6 Mary Godfrey Leeds Institute of Health Sciences Charles Thackrah building Leeds University 101 Clarendon Road Leeds LS2 9LJ 25th February 2009 Dear Mary. Chair of the Faculty Research Ethics Committee. I am pleased to be able to inform you that reviewers acting on behalf of the sub-committee have now granted ethical approval to the above named research proposal. Thank you for submitting your revised research proposal Managing risk of sexual boundary violations in counselling and psychotherapy for ethical review. along with the view of Professor Shickle. The opinion that you obtained from the NHS REC queries line. Kind Regards Laura Stroud Co Chair LIHS/LIGHT Research Ethics sub committee Leeds Institute of Health Sciences Charles Thackrah Building 101 Clarendon Road Leeds LS2 9LJ 108 . provides confirmation that your proposal falls within the remit of the LIHS/LIGHT Research Ethics sub-committee.

Anonymisation The researchers are ultimately responsible for making sure that all potentially identifying details are omitted from the transcripts. Please use the correct spelling of words where at all possible. Int3. Level of transcription Please transcribe the audio-recordings verbatim: that is. Int3: Mm hm.g. The only places to use other spellings are: (1) when a word is started but not completed. Also transcribe hearable confirmations from the listening party which occur while the other person is still talking. we would be grateful if you would follow the guidelines for transcription set out below. In order to help the researchers analyse the transcripts you produce. We would also like you to transcribe parts of words that are spoken but not completed as when someone changes their mind about what they are going to say. the interviewer will be labelled Int1. please transcribe every word in the false start as well as all the words in new start. or Int4. Thank you... (2) where there are hesitations. [name of organization]. Int2: Yeah. Participants will be labelled P1. P2. however. and that you follow the procedures specified on the form. the speakers will be labelled De1. e. e. please transcribe every word that is spoken. Labelling of speakers The researcher with whom you are in contact will let you know how to label the speakers in each recording. De3. if you would omit obviously identifying details such as the names of people and places in your transcript. or De4. De2. „I was very up. Where you omit a potentially identifying detail please put a relevant note in that place. P3 etc. [husband‟s name]. [name of town]. „I I I went home and was so u u upset‟. It is helpful to us if our transcripts are consistent and following these guidelines will facilitate use of tools such as search strategies on the software package we will be using to help us organize our analysis. If it is debrief data.sad‟ (where the word upset was started but not completed).. 109 . Int2. If it is interview data with a research participant. P3: Mm (see transcription examples below). If someone starts a sentence but breaks off and starts again. It would be helpful.g. returned this signed copy to one of the researchers. e.g.Appendix 7 University of Leeds Research into practitioners’ experiences of successfully managing the risk of sexual boundary violations with clients Guide for transcribers Please make sure that you have signed a copy of our Confidentiality Statement for Transcribers form. such as [women‟s name].

(tearful voice).g..g. Strong stress on word Omitted names Overlapping speech 110 . Unclear speech Completely inaudible speech Word started but not completed. R: He said that was impossible.g. I: (overlapping) Who Bob? R: No Larry. up. e. Flag words that are not clear by placing them in square brackets and a question mark if guessing what is said. What do you.g.I don‟t know (where the sentence is not completed). R: At that he just [doubled? glossed?] over.. [inaudible] Indicate when someone‟s speech is broken off midsentence or mid-word by including a hyphen (-) at that point where the interruption occurs: e. [town] Use a hyphen to indicate when one speaker overlaps with another at the transition between speakers and indicate the overlapping speech at the beginning of the interrupting speaker‟s turn.Transcription conventions Below we provide you with a list of transcription conventions that we would like you to use for features of the talk that may be of use to us in our analysis. (sighs) etc.g.not very happy (where the word upset was not completed).. (laughter) to denote several people laughing. Feature of talk Laughing Transcription convention to use Indicate in parenthesis. for example (coughs). for example (laughing) to denote one person. Indicate in parenthesis.. demolish e.. tearful voice etc. interruptions etc. e. e. Coughing.

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