Sex And Psychotherapy

It is, in a way, the ideal setting for extraordinary intimacy. Patient and therapist are isolated from the world, focused on each other intently, exploring long-buried emotions. In successful psychotherapy, patients usually undergo something called transference, in which they come to see the therapist as an all-loving parent they can trust completely. The process can stir feelings in the therapist, too; power is a potent aphrodisiac. Freud warned that therapists should struggle against such "countertransference " and not abuse the patient's longing for love. Yet even some of his closest disciples couldn't withstand the temptations of the couch. Carl Jung took two patients as his mistresses. Otto Rank had a long affair with patient Anais Nin. Sandor Ferenczi believed that his clients needed his physical comfort and openly petted some of them.

History is replete with such indiscretions between psychotherapists and patients, and they've become the standard plot line for popular films from "The Prince of Tides " to "Basic Instinct. " Still, each new incident that comes to light arouses fresh public concern. Last week the case of a Harvard medical student and his Harvard-trained psychiatrist burst out of Boston and made headlines nationwide. The patient, 28-year-old Paul Lozano, had injected himself with a lethal dose of cocaine and his family filed suit, charging that psychiatrist Margaret Bean-Bayog drove him to suicide after an unduly intimate relationship. Bean-Bayog denied any sexual contact with Lozano. But the evidence, including thousands of pages of letters, flashcards and office notes detailing erotic and sadomasochistic episodes (page 56), was clearly disturbing.

Sex between therapists and patients is specifically forbidden by the Hippocratic oath and in the ethics codes of the American Medical Association (AMA), the American Psychiatric Association (APA) and other mental-health groups. Yet the practice clearly goes on. Nobody knows how widespread it is - most studies rely on replies to anonymous questionnaires. In the most authoritative nationwide survey, conducted by psychiatrist Nanette Gartrell in 1986, 7 percent of male psychiatrists and 3 percent of female psychiatrists admitted having sexual relationships with their patients. Even more disturbing, Gartrell later found that 65 percent of therapists said they had treated patients who had been sexually involved with previous therapists. And while respondents said the encounters were harmful to the patients in most of the cases, only 8 percent said they had reported the incidents to authorities.

That reticence reflects a widespread feeling that, in the past at least, the profession has looked the other way when it came to sexual contact with patients. Experts estimate that patients file complaints in only 4 percent of such cases, and relatively few therapists have been severely disciplined. "Too many in the profession have been more concerned with sweeping the problem under the rug, with enabling people to continue practicing ... with making sure the insurance rates stay down, " laments clinical psychologist Kenneth Pope, former chairman of the APA's ethics committee. And because the vast majority of cases involve male therapists and female patients, some experts suspect sexism as well. Says Pope: "In our society, we tend to deny and downplay those types of abuses in which males are the perpetrators. "

But the conspiracy of silence is fast breaking. A spate of widely publicized cases, a series of tell-all books and Hollywood's growing infatuation with the topic (page 58) are forcing the profession to take stronger action. "A lot more cases are being reported, " says Shirley Siegel, cofounder of the group Stop Abuse By Counselors in Seattle. "Women are much more willing to come forward and report embarrassing situations. " Eight states have enacted laws making sex between patients and therapists a crime, and several more are weighing criminal sanctions. That may explain why fewer therapists admit to indiscretions these days even in anonymous surveys: in one recent study, less than 1 percent of respondents said they'd had affairs with patients, down from as many as 12 percent in the late 1970s. "All those people who said yes [they did it] 10 years ago have not died in the past decade, " says psychiatrist Glen O. Gabbard, director of the Menninger Clinic in Topeka, Kans. "People are not being as honest. " Professional associations are also getting tougher about disciplining ethics abuse. The APA now publicizes the fact that in the last 10 years, it has expelled or suspended 113 members, mostly for sexual misconduct.

Interestingly, that number doesn't include John M. Hamilton, a 68-year-old former deputy medical director for the APA. Last month he resigned his post after the Maryland medical board suspended his license for having a two-year affair with a female patient. The relationship came to light only after the woman told a clergyman, who reported it to state authorities. APA officials issued a statement saying they were "shocked and saddened ... but we will not tolerate violations of our ethical code. " Yet it had gone on right under their noses. According to the state board report, which Hamilton did not contest, he even shared a hotel room with the woman at an APA convention in 1990.

Of course, sexual indiscretions occur in other professions as well, from clergymen to teachers to lawyers. In one 1973 California study, more gynecologists and general practitioners admitted having sex with patients than did psychiatrists. But many experts think the temptation to overstep bounds is particularly ripe in mental-health professions. Patients "start to idealize the therapist, " says Chicago psychiatrist Gunnbjorg Lavoll at Northwestern University. "They think, 'How can this wonderful man who is so wise have anything but the most honorable intentions?' " Therapists, in turn, may revel in that feeling, she says. "It makes you feel very powerful to have somebody think you are the greatest person in the world. "

Most experts say a patient's consent is no justification for a sexual encounter. "It's awfully hard for physicians to walk a straight line when somebody's throwing themselves at them, " concedes William Masters of the Masters and Johnson Institute in St. Louis. But he calls such situations "statutory rape " and likens the imbalance of power between therapist and patient to the advantage an older man has over an underage girl. Therapists "have to realize that this is part and parcel of working in the field, " says Masters. "It's still up to them to protect the patient. " Even when therapists think they are in love, experts say, they are serving their own needs, not the patient's, if they act on their impulses.

Are affairs with former patients more acceptable? Some therapists think so, and even the APA ethics code hints at some leeway, saying such relationships are "almost always unethical. " But purists adhere to the maxim "once a patient, always a patient. " Transference can linger for years after therapy has ended, and the anticipation of a later affair can subvert the therapeutic process.

Almost inevitably, patients who sleep with their therapists end up more emotionally scarred than when they began treatment. Sexually abused patients "look very much like incest survivors, " says Gartrell. Many find it difficult to trust subsequent therapists, and most blame themselves for the encounter. In one national survey, Pope found that 11 percent of patients who had sex with their therapists were hospitalized as a result; 14 percent attempted suicide and 1 percent succeeded. "When a therapist engages in sex with a patient, he or she is engaging in a potentially homicidal activity, " Pope says, "far more than getting into a car drunk and driving. "

Lodging a complaint can also be traumatic. The therapist may claim the patient is hallucinating exaggerating or misconstruing what went on, and it's usually one's word against the other's. "I was the mentally ill patient and he was the medical professional with the 30-year practice and a long marriage, " says Julia Peck, a California mother of two who charged that her psychiatrist, Melvin Schwartz, had embraced and caressed her in sessions. The state board did not pursue the case for lack of evidence. Peck, who concedes she was in love with him, filed a civil suit and lost. Schwartz, meanwhile, says Peck had misinterpreted reassuring embraces, which she had requested. "I was really the victim in all this. I was innocent, " he says.

Some patients do misinterpret actions by their therapists. But psychologist Gary Schoener of the Walk In Counseling Center in Minneapolis, who has consulted on more than 2,000 cases in which patients had sexual relationships with therapists, says, "It's extremely rare to have someone literally fabricate a case out of the blue. "

No recent case has rattled the psychiatric establishment more than that of Melissa Roberts-Henry and Denver psychiatrist Jason Richter, profiled on the PBS program "Frontline " last November. Roberts-Henry filed a malpractice suit against Richter in 1987, charging that their three-year sexual relationship had left her in a severely damaged emotional state. Richter admitted to the affair, but his defense lawyers fought back aggressively. They blamed Roberts-Henry's subsequent psychiatrist, Martha Gay, for her deteriorating condition, floated damaging rumors about Gay and probed into Roberts-Henry's sexual past. According to "Frontline, " the APA helped direct Richter's defense because of its ties to a malpractice-insurance carrier that covered him. In the end, the jury awarded Roberts-Henry $180,000, which the APA-sponsored firm helped pay, along with his legal fees. Richter retained his license and continues to practice in Denver.

Nanette Gartrell, the seminal researcher in documenting sexual misconduct in the profession, resigned from the APA to protest its handling of the case. So did Martha Gay, whose practice was so devastated by the rumors that she moved out of state. "I had unwittingly broken a code of silence about the fact that very little happens to perpetrators of this kind of abuse, " she told NEWSWEEK. "I did not realize that this was such a secret. " The APA denies that it had a financial stake in the malpractice carrier, only in the manager services company that oversaw Richter's claim. "The association in no way was defending him for what he did, " says APA spokesman John Blamphin. "We would have liked to see him receive some punishment. " Roberts-Henry, meanwhile, founded a support group for other abuse victims and singlehandedly persuaded the Colorado Legislature to pass a law that prevents the sexual histories of other plaintiffs in patient-therapist civil suits from being entered into evidence in court.

The APA-sponsored insurance company no longer pays civil damages for doctors found guilty of sexual contact with a patient, though it does still pay legal fees for members defending against such suits. Malpractice insurers in general have stopped covering damage claims in sex cases, on the ground that sex between patients and therapists is a willful unethical act and not part of standard treatment. As a result, it has become harder for victims to collect big damage awards, which some experts say is unfortunate. "Sometimes the only way these [victims] can get subsequent treatment is by suing and receiving a settlement which allows them to pay for subsequent treatment, " says Gabbard.

Only state medical boards can actually revoke a therapist's license. But many state boards have large backlogs of complaints. "California is two years behind in reviewing allegations, " says UCLA psychologist Ivan Mensh. "The patient often says, 'Forget it'. " Sometimes no one steps forward to press charges even in celebrated cases. Though it has been widely publicized that the late poet Anne Sexton had an affair with one psychiatrist who treated her, he continues to practice in Boston because she is dead and no other patients have made claims. He refuses to comment. (Even when a license has been revoked, an unscrupulous therapist could hang out a shingle and see patients anyway. And there are legions of untrained "counselors " who treat patients informally and are beyond the reach of professional groups and review boards.)

State regulators' hands are sometimes tied by statutes of limitations. Mary Jo Jacobs was 15 when she first began treatment with Mary Giffin, a respected Chicago psychiatrist. Twenty years later, in 1988, Jacobs filed charges alleging that Giffin's treatment included taking Jacobs's clothes off, grabbing her and performing oral sex. Giffin was expelled from the APA and the Illinois Psychiatric Society, but because Illinois's two-year statute of limitations had expired, her license was not endangered and she continues practicing today. Giffin concedes that she held Jacobs in a form of "touch " therapy but she denies that the contact was sexual and says that Jacobs's memory is distorted. As for losing her professional affiliations, Giffin says: "All that happens is I don't have to pay my dues. "

As unfair as it may seem to bring allegations of impropriety long after the fact, some experts say that is understandable in psychotherapy. "A lot of patients don't come to terms with it for years, " says Colorado attorney Joyce Seelen, who has handled some 50 cases involving sex between patients and counselors. She says that statutes of limitations shouldn't begin running "until the victim understands that the responsibility for the relationship belongs to the therapist. " But getting lawmakers to understand the subtleties of psychotherapy isn't easy. For the last three years, the Massachusetts Legislature has been considering a bill to make therapist-patient sex a felony. "The legislators are opposed, " says attorney Linda Jorgenson. "One of the issues frequently raised about patients is, 'They're adults, they're not psychotic. Why can't they say no?' "

Some experts argue that imposing criminal penalties on sexual misconduct may make therapists less willing to admit their transgressions-and less likely to report colleagues who stray. As it is, many therapists who learn of patients' affairs are reluctant to blow the whistle because of doctor-patient confidentiality. There is also fierce debate over whether practitioners who stray once can be professionally trusted again. The APA ethics committee says some offenders can be "safely rehabilitated " with one to five years of supervision. But Pope thinks no one should be allowed to continue in the profession after a sexual transgression, and he draws an analogy to a preschool administrator who abused children: "No state would allow that person to run another preschool. Why would we even consider letting therapists who have abused their patients return to this work? "

There are some clear warning signs that a counseling relationship is headed for trouble, experts say. California's 1989 guidebook "Professional Therapy Never Includes Sex " warns patients to beware if a therapist or doctor tells sexual jokes, gives seductive looks, sits too close or schedules late appointments. Gabbard says therapists should be on the alert if they find themselves disclosing their own problems to a patient, waiving fees, meeting outside the office, holding hands or making other kinds of physical contact. If so, a consultation with a colleague might be in order. "There is absolutely no circumstance on earth in which any sexual contact is acceptable, " says psychiatrist Susan Fisher, a member of APA's ethics committee. "However it's rationalized, it doesn't do anybody any good, particularly the patient. " For those who spend their lives probing the ambiguities of the subconscious, that should be perfectly clear.

of psychiatrists said they had treated patients who were sexually involved with their previous therapists. They reported only 8% of these cases.

As reported in the American Journal of Orthopsychiatry, 1987.

of male psychiatrists admitted having sexual contact with their patients in an anonymous survey.

of the female psychiatrists admitted it.

As reported in the American Journal of Orthopsychiatry, 1986.