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

by Robert I. Simon

  • The therapist maintains relative therapeutic neutrality, withholding his or her own personal views.

  • The therapist fosters the independence of the patient by maintaining the patient’s psychological separateness from the therapist.

  • The therapist preserves the patient’s confidentiality, an essential element of trust in psychotherapy.

  • The therapist works collaboratively with the patient and obtains informed consent for treatment and procedures.

  • The therapist interacts with the patient primarily through talking.

  • The therapist takes pains to ensure that there are no previous, current, or promised future personal relationships with the patient.

  • The therapist makes sure to minimize physical contact with (and possible erotic stimulation of ) the patient.

  • The therapist avoids burdening the patient with personal disclosures and preserves relative anonymity.

  • A stable fee policy is established, and the therapist accepts only money as payment for treatment.

  • A consistent, private, and professional setting is provided for the therapy—usually, a therapist’s office.

  • Length and time of sessions are clearly defined. Stability and consistency are therapeutically important. Also, clear time definition of sessions eliminates the possibility of extended sessions that may be a part of progressive boundary violations.

  Many of these principles and guidelines apply equally for all physician-patient, lawyer-client, pastor-parishioner, and other professional relationships.

  The Therapy Predators

  Based on my experience assessing what has happened in many cases of alleged sexual misconduct, I can divide the exploitative therapists into five main types: 1) personality disordered, 2) sexually disordered, 3) incompetent, 4) impaired, and 5) situationally stressed. These categories often overlap. I cannot speak authoritatively for all professions, but it is likely that groups such as lawyers, professors, and clergymen contain similar clusters of exploitative individuals.

  Predator therapists are the repeaters, those who sexually exploit numerous patients. These therapists usually display manipulative and exploitative characteristics of a borderline, narcissistic, or antisocial personality disorder. Approximately 40% of the therapists who abuse a patient have abused more than one patient under their care. Sexually disordered therapists are often likely to be repeaters as well. They are subdivided into three categories: frotteurs (compulsive sexual touchers), pedophiles (who use children as sex objects), and sexual sadists. Incompetent therapists may be poorly trained or have persistent boundary blind spots. Sexual misconduct, however, occurs at all levels of training and of professional experience. Impaired therapists’ mishandlings of patients can be traced to abuse of alcohol, drugs, or their own mental or physical illness. Situationally stressed therapists are those who because of painful personal circumstances—such as the loss of a loved one, the experience of marital discord, or a professional crisis— may turn to the patient for repair of their psychological wounds.

  Warning: Patient Vulnerable!

  It is never the patient’s fault when therapist-patient sex takes place. It is always the therapist’s responsibility to maintain the integrity of the treatment and to protect the patient from therapist-induced harm. Approaching the problem of therapist-patient sex as though it might be the patient’s fault is tantamount to “blaming the victim.” Yet it is essential to study all elements of the interaction between therapists and patients that culminate in sexual intimacy to understand how to prevent such sexual abuse from occurring.

  In a study that reviewed more than 2,000 cases of therapist sexual misconduct, no factors were found that predicted patient involvement with therapists. Predictive characteristics were found only for therapists. Nevertheless, the experience of a number of forensic psychiatrists identifies certain patients who appear to be more vulnerable than others to sexual exploitation:

  • Patients with current depression and a recent loss of a love relationship

  • Patients with dependent personalities

  • Patients who have been sexually and physically abused as children

  • Patients with serious psychiatric illnesses or with alcohol and drug abuse problems

  • Patients with impaired mental and personality functions; these patients have low self-esteem, are dependent, have difficulty separating reality from fantasy, are self-destructive, or have impulsive or other maladaptive traits

  • Physically attractive patients with low self-esteem

  • Mentally retarded patients

  • Patients who have had chronic illnesses as children

  Most of these categories are self-explanatory. The terrible combination of impaired mental functioning, low self-esteem, and loneliness often places a patient at risk for sexual exploitation. Any history of childhood sexual and physical abuse, even of severe childhood illness, creates special vulnerabilities. Seductive behavior toward the therapist, for instance, is frequently a consequence of childhood sexual abuse. According to the College of Physicians and Surgeons of the Ontario Task Force Study, 23% of incest victims who seek psychotherapy are sexually abused by the therapist. An additional 23% are victims of other forms of abuse by the therapist. These are shockingly high figures. Only 30% of these patients receive any help from their first therapist. Indeed, the average incest victim sees 3.5 therapists in the course of treatment.

  Childhood sexual abuse tends to create the need to master the original trauma through repetition. It sexualizes subsequent relations, distorts boundary maintenance in the patient’s personal relationships, and induces low self-worth and feelings of guilt. Frequently, patients who were sexually abused in childhood will test treatment boundary limits through seductive behavior in their attempts to determine whether the therapist can be trusted. Also, patients who have suffered child abuse have learned to mentally dissociate themselves while being abused. When such vulnerable patients are sexually approached directly by a therapist, they may psychologically and physically freeze. These patients may mentally dissociate to a corner of the room or feel like they are floating to the ceiling to watch what is occurring, as if it were happening to someone else. In this psychological state, they are easy prey for the predator therapist.

  Patients who have had extensive medical and surgical procedures as children may also be vulnerable as adults to sexual exploitation. They have had their bodies frequently exposed to numerous medical personnel as well as to family members. Also, they have endured intrusive medical procedures that distort body privacy boundaries. These intrusions set the stage for later sexual intimacies with exploitative therapists who do not maintain appropriate boundaries.

  Patients with certain dysfunctional personality characteristics sometimes attempt to manipulate the therapist and draw him or her out of the treatment role. With these patients, therapists are tempted to make frequent exceptions to the rules of treatment. Such patients tend to induce in the therapist the desire to do better than the patient’s parents or other caretakers or to undo the damage to the patient done by them. If the therapist takes this bait, he or she commits a major error. Attempting to “re-parent” the patient is almost always disastrous. Aside from the realization that it is an impossible task, the endless demands that come from the patient when the therapist attempts to reparent interfere with the patient’s more important need to mourn the losses of childhood and move on with life.

  Therapists are trained and expected to appropriately manage difficult patients so that patient exploitation does not occur. If a therapist cannot manage the patient appropriately, and harm threatens the patient, the therapist should refer the patient to a competent therapist.

  After the Bubble Bursts

  The harm caused by therapist-patient sex can be enormous. The psychic pain and damage become particularly apparent after the patient discovers that he or she has been sexually exploited by the therapist. Psychological harm includes worsening and exacerbat
ion of the patient’s preexisting psychiatric conditions; creation of new conditions such as anxiety, depressive disorders, or even psychosis; damage to personal relationships; possible destruction of future treatment possibilities; and suicide. Almost invariably, the patient who has been sexually exploited only becomes fully aware that he or she has been abused after a real or perceived rejection by the therapist. Such feelings of rejection may come as a consequence of the therapy being terminated, the therapist going on vacation, learning that other patients are having sex with the therapist, the refusal of the therapist to leave a spouse or to marry the patient, or any number of other real or perceived acts of rejection. The realization may be sudden or gradual, but it is always devastating. New psychological symptoms may appear, or old ones may be magnified when the sex between patient and therapist stops, termed by some the “cessation phenomenon.” Some patients regress dramatically and become profoundly depressed and suicidal. As for the therapist, there is no golden parachute, no easy disengagement from the situation. Invariably, both patient and therapist are harmed. The patient in a sexual relationship with a therapist is harmed in many ways by the boundary violations that almost always precede actual therapist-patient sex. In such situations, the patient’s original problems, for which he or she sought treatment, are worsened, and an important opportunity to treat those problems is lost. Moreover, when the patient becomes aware of having been exploited, the patient’s sense of being special to the therapist evaporates, leaving instead feelings of profound betrayal, rage, and loneliness.

  The cornerstone of any therapy is trust. Patients who have been sexually exploited by their therapists may have great difficulty undertaking meaningful therapy again because their trust has been shattered. The exploitation strikes at the heart of the patient’s psyche: the critical ability to trust oneself and others. The foundations for basic trust are established in the first few years of life. For example, fundamental beliefs such as that the world is a predictable and rational place, that bad things do not happen to good people, that we have control over life events, and that persons in positions of trust and authority are beneficent and trustworthy develop early in the child raised by goodenough parents. Most people make gradual adjustments in these assumptions as they encounter life’s vicissitudes. It is when fundamental beliefs are dashed suddenly and traumatically that psychic harm results and trust is shattered. Some level of basic trust is necessary in the conduct of almost every aspect of life. For example, we could neither leave the house nor cross the street without trust. The paranoid psychotic individual usually is debilitated by the inability to trust.

  Many exploited individuals do not seek therapy again, losing once and for all the opportunity to regain their mental health. Even if they do try therapy again, the exploited patient’s sense of appropriate treatment boundaries has been gravely distorted. As part of any new therapy, there will have to be hard work both by the patient and the new therapist to reestablish treatment boundaries. If that work is not done, such patients remain quite vulnerable to being exploited yet another time. To break the cycle, it is sometimes useful to refer a sexually exploited patient to a same-sex therapist to allay some of the patient’s anxiety concerning his or her continued vulnerability to exploitation.

  As for the therapist, a clear-headed look at the matter would show any therapist that sexual involvement with a patient is tantamount to committing professional suicide. Such therapists’ professional reputations are usually damaged, if not outright destroyed, when the exploitation of the patient comes to light. The therapist risks having his or her professional license suspended or revoked. Professional organizations may bring up the therapist on ethical charges and even expel the therapist. The therapist risks great collateral damage to his or her family and colleagues. Studies have shown that the knowledge that a close and trusted colleague has had sex with a patient is as great a stress on the clinician as having a patient commit suicide. For the therapist whose sexual exploitation becomes known, he or she is likely to be hit with a civil suit and with attendant sensational media coverage. In certain states, criminal charges may be brought. Financial damages levied against the therapist by the court may not be covered by the therapist’s malpractice insurance. In the end, the abusive therapist may lose everything because he or she had sex with a patient.

  The exploited patient, in addition to being able to seek legal redress through the courts, has recourse through professional organizations and state licensure bodies. However, the patient will need to explore his or her psychological readiness to pursue any of these avenues with a therapist because they are fraught with considerable emotional pain and stress. The patient must resist the temptation to act impulsively and must summon the psychological resources necessary to stay a very difficult course. In many instances, an accused therapist will use all legal means available to fight the patient’s charges. The abused patient’s journey through the legal system is usually another abusive experience. The law is a blunt instrument.

  Here are the legal and professional actions that can be brought against an exploitative therapist at the instigation of a harmed patient:

  • Civil suit

  • Breach of contract action

  • Criminal sanctions

  • Civil action for intentional tort (e.g., battery, fraud)

  • License revocation

  • Ethical sanctions from professional societies

  • Dismissal from professional organizations

  At issue in some of these matters is the statute of limitations. In most cases, the time frame within which a party is permitted to bring a suit is 1 to 2 years after the discovery of an injury. In some cases of sexual exploitation, the law recognizes that the therapist’s negligence may have impaired the ability of the patient to become aware of the psychological injuries that have been produced. The issue of the patient’s competency in this regard may toll—that is, stop—the statute of limitations from running out. Fraudulent concealment by the therapist may also toll the statute of limitations. Patients have been sexually exploited for years without realizing the terrible emotional consequences to themselves, because the power differential between therapist and patient has strengthened the patient’s denial mechanisms. Fraudulent concealment may occur when the therapist misinforms the patient that sex is therapy, or when the therapist fails to inform the patient that what the patient feels for the therapist is not love but transference at work.

  And Ye Shall Know the Truth

  Effective psychotherapy is a joint enterprise based on mutual trust between therapist and patient. But the public is not yet completely aware that therapist-patient sex is malpractice. Prospective patients need to be educated about the establishment of appropriate treatment boundaries. The patient who is well informed can enhance his or her chances of successful treatment by being knowledgeable about what is expected between a therapist and a patient. Radio and television programs, books, and special educational materials can educate people on these matters. The Internet is a useful tool for checking the credentials of a prospective therapist, as well as any adverse actions brought against the therapist. Licensure board websites should be consulted.

  Many patients who enter therapy, particularly for the first time, do not know what constitutes appropriate treatment, nor do they have clear ideas about treatment boundaries. There is also a need for education about what a patient can or should do if he or she has been sexually exploited or feels that the therapist’s behavior has been inappropriate and harmful. Studies show that sexually exploited female patients lack knowledge of complaint procedures rather than lacking motivation to take action on their own behalf.

  It is a matter of “uh-oh” versus “ah-ha.” Patients who sense that they are being exploited often have an “uh-oh” reaction about what is happening to them. However, patients who are receiving proper benefit from their therapy will often have an “ah-ha” reaction to insight and psychological growth.

  For patients who want to e
valuate their own therapy experience, the Wisconsin Task Force on Sexual Misconduct has published guidelines, recommending protective options for patients who feel they are threatened with exploitation or who have already been exploited.

  The following questions can alert patients, or therapists themselves, to the possibility that therapeutic boundaries are being crossed:

  1. Is the therapist requesting or pressuring the patient to perform any personal task, or to join in any activity that appears to be for the primary benefit of the therapist?

  2. Is the therapist-patient relationship becoming less professional and more social over time?

  3. Is the therapist revealing highly personal information about himself or herself?

  Prevention requires diligent efforts in several directions, in addition to public education. Among the other directions are the selection of appropriate candidates as future therapists, the professional education and supervision of practicing therapists, and the toughening of ethical, professional, and legal sanctions against offending therapists. Prevention will never be total or perfect. All therapists are human and therefore imperfect. Sexual involvement of therapists with patients, though reprehensible, is likely to remain an occupational hazard for therapists and a danger for patients. Humankind’s darker side ensures that this danger can never be completely eliminated.

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  9

  You Only Die Once— But Did You Intend It?

  The Forensic Psychiatrist As Sleuth

  Doubt is not a very pleasant condition, but certainty is absurd.