Sexual Attraction to Clients:
The Human Therapist and the (Sometimes) Inhuman Training System
ABSTRACT: Although we currently possess considerable information about the incidence and consequences of sexually intimate relationships between psychotherapists and clients, there is virtually no documentation of the extent to which psychotherapists are sexually attracted to clients, how they react to and handle such feelings, and the degree to which their training is adequate in this regard. Feelings toward clients are generally relegated to vague and conflicting discussions of countertransference, without benefit of systematic research. Survey data from 575 psychotherapists reveal that 87% (95% of men, 76% of women) have been sexually attracted to their clients, at least on occasion, and that, although only a minority (9.4% of men and 2.5% of women) have acted out such feelings, many (63%) feel guilty, anxious, or confused about the attraction. About half of the respondents did not receive any guidance or training concerning this issue, and only 9% reported that their training or supervision was adequate. Implications for the development of educational resources to address this subject are discussed.
CITATION & COPYRIGHT: This article was published in American Psychologist, vol. 41, #2, pages 147-158. The American Psychological Association holds the copyright. The copy of record is online at http://dx.doi.org/10.1037/1931-3918.S.2.96
Although the primary focus of this article is the presentation of data concerning therapists’ sexual attraction to their clients and the implications for education and training, the context within which this research was conducted should be noted. Sexually intimate behavior between therapists and their clients has emerged as an increasingly serious problem within the profession, as revealed by an examination of the records in three arenas—ethics cases, malpractice suits, and licensing board hearings.
Ethics cases concerning therapist-client sex have seized popular and professional attention, but ethical standards prohibiting this activity date back at least as far as the Hippocratic Oath: In every house where I come, I will enter only for the good of my patients, keeping myself far from all intentional ill-doing and all seduction, and especially from the pleasures of love with women and men (Dorland’s Medical Dictionary, 1974, p. 715). The American Psychological Association (APA), however, did not explicitly prohibit sexual intimacies with clients until the late 1970s (APA, 1977). Over the subsequent decades, a large proportion of the formal ethics complaints filed against psychologists allege behaviors related to therapist-client sexual involvement (Pope & Vasquez, 1999).
Similarly, during this period, malpractice cases have shown a sharp increase. Asher (1976) reported that the previous insurance carrier had declined to provide further coverage to psychologists because sexual intimacy cases had accounted for 5 of the approximately 45 claims since the start of coverage in 1974. An actuarial study of the malpractice suits filed against psychologists over a 15 year period showed that therapist-patient sexual involvement accounted for the largest category (Pope & Vasquez, 1999).
In a third arena, licensing, complaints concerning therapist-client sexual intimacy became a focus both of the activity of the state psychology boards (Pope, 1993) and of the consequent civil litigation reviewing the boards’ authority. The psychology licensing boards’ authority to take actions regarding therapist-client sexual relations involving psychologists (and, with few exceptions, other therapists) was not upheld by the courts until the 1970s. For instance, as late as 1965, the Colorado Supreme Court, in Colorado State Board of Medical Examiners v. Weiler (1965), thwarted the board’s attempt to revoke a therapist’s license for his allegedly creating a treatment plan involving intercourse for his female patient with himself as her partner. In Morra v. State Board of Examiners of Psychologists (1973), however, the Kansas Supreme Court affirmed the right of the board to revoke the license of a psychologist who had tried to persuade two of his patients to engage in sexual intimacies with him. Likewise, in Cooper v. Board of Medical Examiners (1975), a California Appellate Court upheld the right of the board to revoke a psychology license primarily on the basis of sexual intimacies between the psychologist and three patients. For a history of such legal actions, see Pope (1994).
There was only one attempt prior to the 1970s to conduct systematic empirical studies of the actual behavior of therapists in this regard. In 1938, Glover (1955) surveyed members of the British Psychoanalytical Society. The form was extraordinarily long, complex, and detailed (yet yielded an 83% return rate), inquiring into virtually all aspects of the members’ work and relationships with their patients. There was no report of analyst-patient sexual intimacy. In fact, virtually all respondents reported avoidance of social (‘fringe’) contact during analytical sessions and limitation of small talk. Over two thirds of the sample reported that they took special measures to avoid extraanalytical contact during analysis.
Forer, in an unpublished 1968 survey (B. Forer, personal communication) of the members of the Los Angeles County Psychological Association, found that 17% of the men in private practice indicated that they had engaged in therapist-client sexual intimacies, whereas no such sexual experiences were reported by women in private practice or by men working in institutional settings. Kardener, Fuller, and Mensh (1973) surveyed the male members of the Los Angeles County Medical Society. Ten percent of the subsample of psychiatrists reported engaging in erotic contact with clients, with 5% reporting sexual intercourse.
Two initial national studies of therapist-client sex, both limiting their sample to psychologists. Holroyd and Brodsky (1977) found that 7.7% of their sample of psychologists conducting psychotherapy answered positively any of the questions regarding erotic-contact behaviors or intercourse during treatment (pp. 847-848). Pope, Levenson, and Schover (1979) found that 7% of their sample of psychologists conducting psychotherapy reported engaging in sexual intimacies with their clients. Please follow this link for a table presenting the results of the 8 national studies of therapist-patient sex published in peer-reviewed journals.
(Chart adapted from the book Sexual Involvement with Therapists: Patient Assessment, Subsequent Therapy, Forensics)
|Study||Publication date||Discipline||Sample size||Return rate||% Male Therapists Reporting Sex With Clients||% Female Therapists Reporting Sex with Clients|
|Holroyd & Brodsky 2||1977||psychologists||1,000||70%||12.1%||2.6%|
|Pope, Levenson & Schover||1979||psychologists||1,000||48%||12.0%||3.0%|
|Pope, Keith-Spiegel & Tabachnick||1986||psychologists||1,000||58.5%||9.4%||2.5%|
|Gartrell, Herman, Olarte, Feldstein & Localio 3||1986||psychiatrists||5,574||26%||7.1%||3.1%|
|Pope, Tabachnick & Keith-Spiegel.4||1987||psychologists||1,000||46%||3.6%||0.4%|
|Borys & Pope.6||1989||psychiatrists, psychologists & social workers||4,800||56.5%||0.9%||0.2%|
|Bernsen, Tabachnick & Pope||1994||social workers||1,000||45.3%||3.6%||0.5%|
1 This chart presents only national surveys that have been published in peer-reviewed scientific and professional journals. Exceptional caution is warranted in comparing the data from these various surveys. For example, the frequently cited percentages of 12.1 and 2.6, reported by Holroyd and Brodsky (1977), exclude same-sex involvements. Moreover, when surveys included separate items to assess post-termination sexual involvement, these data are reported in footnotes to this table. Finally, some published articles did not provide sufficiently detailed data for this table (e.g., aggregate percentages); the investigators supplied the data needed for the chart.
2 Although the gender percentages presented in the chart for the other studies represent responses to one basic survey item in each survey, the percentages presented for Holroyd & Brodsky's study span several items. The study's senior author confirmed through personal communication that the study's findings were that 12.1% of the male and 2.6% of the female participants reported having engaged in erotic contact (whether or not it included intercourse) with at least one opposite-sex patient; that about 4% of the male and 1% of the female participants reported engaging in erotic contact with at least one same-sex patient; and that, in response to a separate survey item, 7.2% of the male and 0.6% of the female psychologists reported that they had "had intercourse with a patient within three months after terminating therapy" (p. 846; see also Pope, Sonne, & Holroyd, 1993).
3 "Respondents were asked to specify the number of male and female patients with whom they had been sexually involved" (p. 1127); they were also asked "to restrict their answers to adult patients" (p. 1127).
4 The survey also included a question about "becoming sexually involved with a former client" (p. 996). Gender percentages about sex with current or former clients did not appear in the article but were provided by an author. Fourteen percent of the male and 8% of the female respondents reported sex with a former client.
6 This survey was sent to 1,600 psychiatrists, 1,600 psychologists, and 1,600 social workers. In addition to the data reported in the table, the original article also asked if respondents had "engaged in sexual activity with a client after termination" (p. 288). Six percent of the male and 2% of the female therapists reported engaging in this activity.
(For a discussion of these national studies and their implications, see Sexual Involvement with Therapists: Patient Assessment, Subsequent Therapy, Forensics.)
Despite dated, isolated claims about the benefits—or at least lack of harm—associated with therapist-client sex (McCartney, 1966; Romeo, 1978; Shepard, 1971), research has shown the harmful phenomena that can be associated with such behavior. Basing her analysis on an original study and a review of previous research (such as Belote, 1974; Chesler, 1972; Dahlberg, 1971; Taylor & Wagner, 1976), Durre (1980) concluded that "amatory and sexual interaction between client and therapist dooms the potential for successful therapy and is detrimental if not devastating to the client" (p. 243). Durre’s research cited "many instances of suicide attempts, severe depressions (some lasting months), mental hospitalizations, shock treatment, and separations or divorces from husbands. . . . Women reported being fired from or having to leave their jobs because of pressure and ineffectual working habits caused by their depression, crying spells, anger, and anxiety" (p. 242).
Bouhoutsos, Holroyd, Lerman, Forer, and Greenberg (1983) found that in 90% of the reported cases of therapist-client sexual intimacies, clients were damaged (according to their subsequent therapists). The harm ranged from inability to trust and hesitation about seeking further help from health (or other) professionals, to severe depressions, hospitalizations, and suicide. Pope and Vetter (1991) published a national study of 958 patients who had been sexually involved with a therapist. The findings suggest that about 90% of patients are harmed by sex with a therapist; 80% are harmed when the sexual involvement begins only after termination of therapy. About 11% required hospitalization; 14% attempted suicide; and 1% committed suicide. About 10% had experienced rape prior to sexual involvement with the therapist, and about a third had experienced incest or other child sex abuse. About 5% of these patients were minors at the time of the sexual involvement with the therapist. Of those harmed, only 17% recovered fully. For a review of the research on the harmful phenomena that can be associated with sexual involvement between therapists and clients, see Pope (1990, 1994).
We have begun to explore instances in which a psychologist acts out a sexual attraction to a client and thus violates the prohibition. But, especially in terms of research, we know virtually nothing about the attraction itself. What seems to cause this attraction? How frequently does it occur among all therapists, not just those who become sexually intimate with their clients? Do therapists feel uncomfortable, guilty, or anxious when they notice such attraction? Do they tell their clients? Do they consult with their colleagues? Why do therapists refrain from acting out this attraction (in cases when they do refrain)? In what instances is it useful and beneficial to the therapy? In what instances is it harmful or an impediment? Do therapists believe that their graduate training provided adequate education regarding attraction to clients?
The primary purposes of this article are to raise such questions, to initiate serious discussion and research by providing data, and to examine implications for psychology training.
Views on Therapists’ Attractions to Clients
When the subject of therapist-client attraction was originally addressed in the literature—unfortunately in the absence of systematic research—the discussion was almost exclusively in terms of transference and countertransference. In her review of this literature, Tower (1956) noted that virtually every writer on the subject of countertransference stated unequivocally that no form of erotic reaction to a patient is to be tolerated.
Within the psychoanalytic framework, a therapist’s attraction to a client was originally seen as a reaction to the client’s transference. In 1915, Freud stressed that the patient’s transference must be understood as a specific therapeutic phenomenon not identical to the experience of falling in love as it occurs outside the context of therapy. The analyst "must recognize that the patient’s falling in love is induced by the analytic situation and is not to be ascribed to the charms of his person, that he has no reason whatsoever therefore to be proud of such a conquest, as it would be called outside analysis" (Freud, 1915/1963).
Freud wrote that he emphasized this phenomenon of "transference love" because it "occurs so often," because "it is so important in reality and . . . its theoretical interest," and because his writings on the subject could provide the analyst with "a useful warning against any tendency to counter-transference which may be lurking in his own mind."
This countertransference that Freud felt the analyst must be warned against was a reaction to the patient’s transference rather than to the patient himself or herself. Kernberg (1975) stated the classical definition of countertransference as "the unconscious reaction of the psychoanalyst to the patient’s transference." That is, in the same way that the analyst could not ascribe the patient’s love to the "charms of his person," the analyst’s response was not to the charms of the patient but rather a reaction to the transference.
Freud believed strongly that this countertransference must never be acted out. "If her advances were returned, it would be a great triumph for the patient, but a complete overthrow for the cure. . . . The love-relationship actually destroys the influence of the analytic treatment on the patient; a combination of the two would be an inconceivable thing" (Freud, 1915/1963).
The classical view of countertransference, as first set forth by Freud, became the predominant view. The defining characteristics were as follows: (a) The therapist’s reaction is irrational or distorting—that is, a transference; and (b) the therapist is reacting to the client’s transference.
Proponents of the classical view are numerous. Grossman (1965), for example, proposed that the word countertransference be limited to mean only one thing: reaction to transference. Ruesch (1961) maintained: "Countertransference is transference in reverse. The therapist’s unresolved conflicts force him to invest the patient with certain properties which bear upon his own past experiences rather than to constitute reactions to the patient’s actual behavior. All that was said about transference, therefore, also applies to counter-transference, with the addition that it is the transference of the patient which triggers into existence the countertransference of the therapist." In a similar vein, Greenson (1967) wrote, "Errors due to countertransference arise when the analyst reacts to his patient as though the patient were a significant person in the analyst’s early history. Countertransference is a transference reaction of an analyst to a patient, a parallel to transference, a counterpart of transference."
The development of this conceptualization regarding countertransference had a number of implications for the conceptualization of a therapist’s attraction to a client. First, the attraction was viewed as countertransference. Second, because countertransference represented the therapist’s own transference, the therapist was involved in a distortion (seeing the client in terms of a figure or conflict from the therapist’s past) of which he or she was unaware. Third, because the countertransference was an inappropriate or irrational response to the client’s transference, the therapist was, in effect, mishandling the transference phenomenon. As a result, a therapist’s attraction to a client became, almost by definition, a therapeutic error, something to hide and to be ashamed of.
The work of Winnicott (1949), Heimann (1950), and Little (1951) formed the impetus for a substantial literature asserting that counter-transference, correctly managed, is a valuable therapeutic resource (e.g., Singer, 1970; Tauber, 1979; Weiner, 1975). However, the idea that countertransference, despite its positive potential, also constitutes a weakness or error antithetical to the goals of therapy remained widespread. Typical writings assert that countertransference reactions are "undesirable and the analysis would be better off without them" (Baum, 1969-1970); that "countertransference is by definition a distraction from an important goal of psychotherapy" (Weiner, 1978); and that the phenomenon comprises "not only the analyst’s personal neurotic tendencies. . . but also. . . blind spots and limiting factors" (Cohen & Farrell, 1984). Langs (1973) developed the thesis that virtually all mistakes committed by well-trained and experienced therapists are caused directly by countertransference. "Unrecognized countertransference is the single most frequent basis for therapeutic failure. It is countertransference, rather than transference. . ., that is by far the hardest part of analysis—and therapy" (Langs, 1982).
Taken as a whole, the literature indicates that the failure to acknowledge and examine countertransference blocks its therapeutic potential and unleashes its destructive effects. Consequently, to the degree that sexual attraction is considered countertransference, it is particularly regrettable when training systems fail to promote the acknowledgment and examination of this phenomenon. Interestingly, this psychodynamic conceptualization of the client’s attraction to the therapist as transference, the therapist’s attraction to the client as countertransference, and the necessity of avoiding a therapist-client "love affair" so that the transference can be adequately handled and the treatment can continue, found their way into our legal standards. In Zipkin v. Freeman (1968), a female plaintiff had been referred to a psychiatrist for treatment of headaches and diarrhea. According to court records, the symptoms were gone after a couple of months, but the woman agreed to continue treatment in order to get at the underlying causes of her difficulties. She came to feel more and more affectionate toward her therapist. She claimed that when she told him she was in love with him, he said that the feeling was mutual. According to her testimony, the therapist advised her to leave her husband and live in a room above the therapist’s office. (She later moved to a farm in which the therapist had invested.) She recounted that they engaged in sex together, that they traveled outside the state together, and that she attended "group therapy" that involved nude swimming. On the basis of these and other allegations, the psychiatrist was successfully sued for malpractice.
In writing his opinion for the majority of the Missouri Supreme Court in this case, Judge Seiler stated, "The gravamen of the petition is that the defendant did not treat Mrs. Zipkin properly and as a result she was injured. He mishandled the transference phenomenon, which is a reaction the psychiatrists anticipate and which must be handled properly" (Zipkin v. Freeman, 1968).
The judge expanded this theme: "Once Dr. Freeman started to mishandle the transference phenomenon, with which he was plainly charged in the petition and which is overwhelmingly shown in the evidence, it was inevitable that trouble was ahead. It is pretty clear from the medical evidence that the damage would have been done to Mrs. Zipkin even if the trips outside the state were carefully chaperoned, the swimming done with suits on, and if there had been ballroom dancing instead of sexual relations" (Zipkin v. Freeman, 1968).
The case of Zipkin v. Freeman had two interesting implications. First, it conceptualized the therapist-client sexual intimacy in terms of transference and the therapist’s handling of that transference. Thus, therapists— even those whose theoretical orientation does not include the transference concept—might be held accountable for the inappropriate handling of a phenomenon that they may view as an invalid concept or at least one with minimal importance for therapy. Second, in discussing therapist-client sexual intimacy in terms of the therapist’s responsibility to handle appropriately the transference, the court indicated that even less extreme expressions of the therapist’s attraction to the patient (e.g., swimming, dancing) may constitute malpractice.
The mental health professions, despite the citations mentioned above, seem to shy away from dealing in an honest, open way with the phenomenon of sexual attraction to clients. Yet, it should be, in our opinion, a central issue in the training of psychotherapists. In addition, the distinctly negative view regarding attraction to clients has led many therapists to develop what Tower (1956) termed "countertransference anxieties." These anxieties have affected the ways in which therapists relate to their patients and conduct therapy. For example, Thompson (1950) stated that "because of the stress on the unfortunate aspects of the analyst’s involvement, the feeling grew that even a genuine objective feeling of friendliness on his part was to be suspected. As a result many of Freud’s pupils became afraid to be simply human and show the ordinary friendliness and interest a therapist customarily feels for a patient. In many cases, out of a fear of showing counter-transference, the attitude of the analyst became stilted and unnatural" (for additional discussion of this issue, see Pope, Sonne, & Holroyd, 1993).
A stilted, unnatural manner and the suppression of ordinary friendliness and interest are but a few of the detrimental effects of making attraction to clients taboo. In many cases, clients may be punished for their sexual feelings. Fine (1965) described how a therapist, reacting inappropriately to the strong sexual desire of the patient, may harmfully misdiagnose the patient. In other cases the therapist may be held to blame for the client’s sexual feelings. Kaplan (1977) wrote, "If one of our trainees reports more than once a year an erotic response on the part of the patient, we assume that he is doing something seductive, something countertransferential that is outside of his awareness." In still other cases, the taboo on attraction may influence therapists’ choice of clients. The data of Abramowitz, Abramowitz, Roback, Corney, and McKee (1976), for instance, suggested that female therapists actively avoid treating attractive male clients.
In such an anti-libidinal atmosphere, it is little wonder that even such an experienced, well-respected, authoritative therapist as Searles described the courage it required for him to publish his work concerning genital excitement during analytic hours as well as erotic and romantic dreams about patients. "I reacted to such feelings with considerable anxiety, guilt, and embarrassment" (Searles, 1959/1965). An analogue study by Schover (l981) found male therapists reacting "with anxiety and verbal avoidance of the material" when a female client discussed sexual material.
If such feelings are intimidating for experienced therapists, they pose an even greater problem for therapists in training. Tower (1956) described the erotic feelings and impulses that she believed virtually all therapists feel toward their patients, and the fears and conflicts regarding these feelings that lead therapists to withhold discussing the attraction with their own therapists or supervisors. In discussing supervision in training institutions, Lehrman (1960) maintained that "such guilt-ridden erotic feelings are a major, if not the major, problem of young male psychotherapists treating attractive female patients."
Given the taboos against acknowledging attraction to a client, the lack of virtually any systematic research in the area is understandable. Yet it is dismaying. An understanding of this phenomenon, based upon empirical data, could form a crucial but long-neglected part of our training as psychologists.
Most graduate programs have not dealt with this issue (Holroyd, 1983; Kenworthy, Koufacos, & Sherman, 1976; Landis, Miller, & Wettstone, 1975; Pope & Tabachnick, 1993; Pope, Sonne, & Holroyd, 1994). Indeed, the sexual attraction experienced between those involved in the training programs themselves may be a troublesome and difficult-to-address part of the problem. Research by Pope, Levenson, and Schover (1979) revealed that, nationwide, 10% of the students within psychology graduate training programs engaged in sexual relationships with their teachers and clinical supervisors. One out of four recent female graduates had engaged in such sexual relationships. Thirteen percent of the educators engaged in relationships with their students and supervisees. Only 2%, however, believed that such relationships could be beneficial to trainees and educators. These practices present a variety of serious clinical, ethical, and legal dilemmas for psychology educators and students (Pope, Schover, & Levenson, 1980).
The extent to which such relationships exert a "modeling effect" for later professional behavior as a therapist awaits more systematic research. However, the initial research (Pope, Levenson, & Schover, 1979) produced preliminary evidence suggesting the possibility of just such an association. For women, sexual contact as students was related to later sexual contact as professionals. That is, 23% of the women who had had sexual contact with their educators also reported later sexual contact with their clients, whereas only 6% of those who had had no sexual contact with their educators had sexual contact as professionals with clients. The sample of men who had had sexual contact with their educators was too small to test the relationship to later sexual contact as professionals with clients.
The profession of psychology would benefit from a careful examination of the attraction therapists feel for their clients. The study reported in the following sections represents an attempt to gather relevant information.
A cover letter, a brief 17-item questionnaire (15 structured questions and 2 open-ended questions), and a return envelope were sent to 1,000 psychologists (500 men and 500 women) randomly selected from the members of Division 42 (Psychologists in Independent Practice) as listed in the APA Membership Register. The anonymous questionnaires were numbered in the order received and transferred to a data file for statistical analysis.
The questionnaire requested respondents to provide information about their gender, age group, and years of experience in the field. Information was elicited about the respondents’ incidence of sexual attraction to male and female clients; reactions to this experience of attraction; beliefs about the clients’ awareness of and reciprocation of the attraction; the impact of the attraction on the therapy process; how such feelings were managed; the incidence of sexual fantasies about clients; why, if relevant, respondents chose to refrain from acting out their attraction through actual sexual intimacies with clients; what features determined which clients would be perceived as sexually attractive; incidence of actual sexual activity with clients; and the extent to which the respondents’ graduate training and internship experiences had dealt with issues related to sexual attraction to clients.
Questionnaires were returned by 585 respondents (58.5%). Of these, 339 (or 57.9% of the sample) were men, and 246 (or 42.1% of the sample) were women. The return-rate difference between male and female respondents was significant, chi-square (1, N = 1,000) = 35.62, p < .001. Sixty-eight percent of the male respondents returned their questionnaires as compared to 49% of the female respondents. The differential return rate resulted in a male-to-female therapist ratio of about 1.4:1. In an effort to shed light on the reason for this differential return rate, we sent a brief follow-up letter three months later to 100 female respondents randomly selected from the original survey sample, requesting information about their response to the questionnaire; if they had not returned the questionnaire, we asked why. The responses of the 40 female psychologists who responded only to the follow-up were not very helpful in illuminating the reasons for the discrepancy. The single most common response was too busy.
Approximately half (48.9%) of the respondents were between the ages of 30 and 45; 39.0% were between 46 and 60; and 12.1% were over 60 years of age. For purposes of descriptive convenience, respondents 45 years of age and under are designated as the younger therapists and those 46 and over are designated as the older therapists. Two hundred and eighty-six respondents (172 men and 114 women) were younger therapists; 299 respondents (167 men and 132 women) were older therapists.
Respondents averaged 16.99 (SD = 8.43) years of professional experience, with no significant differences between male and female psychologists. Younger therapists averaged 11.36 (SD = 3.93) years of experience, and older therapists averaged 21.79 (SD = 8.13) years of experience.
Rate of Therapists’ Sexual Attraction to Male and Female Psychotherapy Clients
Only 77 of the 585 respondents reported never being attracted to any client. Significantly more therapists, then, were attracted to at least one client than not, chi-square (1, N = 585) = 317.54, p < .003. [Footnote: Most of the analyses in this article utilized 3-way tests of association (logit) analyses. These were used to evaluate the response categories as a function of sex and age (under 45 and over 45 years of age) categories. Of interest were the 3-way associations among response, age, and sex; the 2-way associations between response and sex and between response and age; and the test for equal frequency of the use of response categories. In all planned analyses, we used the more conservative tests for each effect at p < .003 to compensate for the increased probability of Type I error with multiple tests. Similarly, ANOVA results were evaluated at p < .003. For post hoc comparisons, the significance level was set at p < .00l.] Among the 508 who were attracted, 125 reported attraction to male clients only, 281 to female clients only, and 102 to both male and female clients.
Table 1 presents the frequencies and percentages of attractions for the sex and age groups of the therapists.
Types of clients to whom therapist is attracted
|none %||male only
|both male & female
|both male & female
Table 2 describes in detail the frequencies and percentages of attraction to male and female clients by male and female therapists.
A 2 X 2 X 2 between-within-within unweighted means ANOVA was performed on therapist rate of attraction to clients as a function of therapist age category (younger and older), sex of therapist, and sex of client. The rating scale was based on frequency of attraction. Respondents indicating that they were never attracted to a client received a 1, respondents who were rarely attracted (operationally defined as once or twice in the survey form) received a 2, those who were occasionally attracted (operationally defined as 3 to 10 times) received a 3, and frequently attracted therapists (operationally defined as more than 10 times) received a 4.
Results indicated that male therapists were significantly more often attracted to clients (mean rating = 1.98) than were female therapists (M = 1.70), F(1, 575) = 41.00, p < .003, that younger therapists were significantly more often attracted to clients (M = 1.94) than were older therapists (M = 1.74), F(l, 575) = 22.32, p < .003, and that therapists generally were more attracted to female (M = 2.16) than to male (M= 1.55) clients, F(l, 575) = 135.29, p < .003.
An expected significant interaction between therapists’ sex and the sex of clients to whom the therapists were attracted indicated that male therapists were more often attracted to female (M 2.77) than male (M 1.18) clients and female therapists were more often attracted to male (M = 2.08) than female (M = 1.32) clients, F(1, 575) = 1877.79, p < .003.
An additional interaction between the sex of the therapists and the age of the therapists indicated a larger sex difference in rate of attraction for older therapists, F(1, 575) = 10.68, p < .003. Younger therapists of both sexes differed little in their rate of attraction to clients (M = 2.01 for male therapists; M = 1.88 for female therapists). But among older therapists, the older women were less often attracted to clients (M = 1.53) than were the older men (M = 1.95).
Contemplation of Sexual Involvement with Clients, Fantasies, and Actual Involvement
The vast majority of respondents (82%) reported that they had never seriously considered actual sexual involvement with a client, chi-square (1, N = 581) = 259.44, p < .003. Of the 104 therapists who had considered sexual involvement, 91 had considered it only once or twice. Male therapists had considered sexual involvement with clients more than had female therapists (27% vs. 5%), chi-square (1, N = 581) 51.85, p < .003. Therapists did not differ significantly according to age.
A content analysis was performed on responses to an open-ended question, In instances when you were attracted [to a client] but did not become sexually involved, why did you refrain from the involvement?" Many respondents offered more than one reason, with the result that there were 1,091 separate content items.
Table 3 lists the major reasons offered in order of frequency mentioned. Patterns were proportionately similar for male and female therapists except for two categories, fear of retaliation by clients and the illegality factor, which were offered only by male therapists as reasons for not acting out sexual feelings toward clients.
|Against therapists' personal values||133|
|Therapist already in a committed relationship||67|
|Fear of censure/loss of reputation||48|
|Damaging to therapist||43|
|Disrupts handling of transference/countertransference||28|
|Fear of retaliation by client||19|
|Attraction too weak/short-lived||18|
Respondents were asked, "While engaging in sexual activity with someone other than a client, have you ever had sexual fantasies about someone who is or was a client?" Most therapists (71.3%) reported that they never had such fantasies, chi-square (1, N = 513) = 183.1, p < .003. Such fantasies were reported to have occurred rarely by 19.3%, occasionally by 8.6%, and frequently by 0.7%. Male therapists reported having more sexual fantasies about clients than did female therapists (27% vs. 14%), chi-square (1, N = 513) = 12.55, p < .003. Younger therapists were more likely to have had such fantasies about clients than were older therapists (28% vs. 14%), chi-square (1, N = 513) = 13.58, p<. 003.
The vast majority of respondents (93.5%) have never acted out sexually with their clients, chi-square (1, N = 569) = 515.02, p < .003. Sexual intimacies with clients occurred rarely (once or twice) for 5.6% of the sample, occasionally (3 to 10 instances) for 0.7%, and frequently (more than 10 times) for 0.2% (one respondent). Male therapists engaged in sexual intimacies with clients more often than did female therapists (9.4% vs. 2.5%), chi-square (1, N = 569) = 11.94, p < .003.
Characteristics of Clients to Whom Therapists Are Sexually Attracted
Client characteristics that elicited feelings of sexual attraction from therapists were assessed by an open-ended question: "How would you describe the clients to whom you've been attracted? Are there any particular salient qualities or similarities among them?" Fifty-nine respondents who did report being sexually attracted to clients indicated that they could not discern any particular similarities or stated that they were the same characteristics they found sexually attractive in people who were not clients, but they did not elaborate what these were.
Over 80% of the respondents who reported being attracted to clients did offer one or more characteristics. The 997 descriptive items were sorted into 19 content categories presented in order of frequency as Table 4. Male and female therapists' responses were fairly balanced proportionately for all of the categories except two. "Physical attractiveness" was mentioned far more often by men (209 times) than by women (87 times), and "successful" was mentioned more often by women (27 times) than by men (6 times).
|Characteristics of Clients to Whom Psychotherapists Are Attracted||Social Workers||Psychologists|
|Positive mental/cognitive traits or abilities||84||124|
|Positive overall character/personality||58||84|
|Fills therapist's needs||8||46|
|Other specific personality characteristics||27||14|
|Resemblance to someone in therapist's life||14||12|
|Availability (client unattached)||0||9|
|Sociability (sociable, extroverted, etc.)||0||6|
|Same interests/philosophy/background to therapist||10||0|
The data about psychologists in the previous table come from a national study published as "Sexual attraction to patients: The human therapist and the (sometimes) inhuman training system" by Kenneth S. Pope, Patricia Keith-Spiegel, and Barbara G. Tabachnick, American Psychologist, vol. 41, pages 147-158 The data about social workers in the following table come from a national study published as "National survey of social workers' sexual attraction to their clients: Results, implications, and comparison to psychologist" by Ann Bernsen, Barbara G. Tabachnick, and Kenneth S. Pope, Ethics & Behavior, vol. 4, pages 369-388.
Therapist Assessment of and Reactions to Client Attraction
Respondents who reported attraction to clients were asked if sexual attraction toward clients had ever been beneficial to the therapy process. More therapists (69%) than not said that their sexual attraction had been beneficial in at least some instances, chi-square (1, N = 464) = 66.87, p < .003. There was a tendency for male therapists to report more beneficial effects than did female therapists (73% vs. 60%), chi-square (1, N = 464) = 8.17, p = .004.
Regarding potential negative effects, respondents were asked if their sexual attraction had ever been harmful or an impediment to the therapy process. Half (49.3%) of the therapists indicated that their sexual attraction had, at least on occasion, exerted a negative influence. Female therapists were more likely than male therapists to report that their sexual attraction was never harmful (60% vs. 44%), chi-square (1, N = 485) = 12.98, p < .003. Younger and older therapists did not differ significantly in this respect.
A post hoc comparison revealed that the significant sex-by-harm interaction was eliminated if those who believed that the clients were aware of the therapist's attraction were selected out and compared on the negative effect item. Thus, it appears that if the client is believed to be aware of the therapist's attraction, the therapy is more likely to be perceived as harmed or impeded (68%) than if the client is believed to be unaware (42%), chi-square (1, N = 472)= 26.42, p<. 001.
To assess therapists' concern about their attraction to clients, respondents were asked, "When you are attracted to a client, does it tend to make you feel uncomfortable, guilty, or anxious?" More therapists indicated experiencing such feelings (63%) than not, chi-square (1, N = 488) = 32.98, p < .003. Younger therapists tended to feel more discomfort than did older therapists (69% vs. 57%), chi-square (1, N= 488) = 7.49, p = .006. No significant differences emerged between male and female therapists in this regard.
Client Awareness and Mutuality of Attraction
Respondents who had been attracted to clients were asked, "In instances when you were attracted to a client, was the client aware of it?" More therapists (71%) believed that the client was probably not aware than believed that the client was aware, chi-square (1, N = 492) = 88.97, p < .003.
Female therapists were more likely than male therapists to believe that their clients were unaware of the attraction felt toward them (81% vs. 65%), chi-square (1, N= 492) = 14.53, p < .003. For this item, a significant three-way association emerged. Older male therapists were more likely than younger ones to believe that clients were aware of their attraction (40% vs. 30%), whereas younger female therapists were more likely than older ones to believe that clients were aware of the attraction (26.5% vs. 11%), chi-square (1, N=492)= 18.74, p< .003.
Mutuality was assessed by the question, "In instances when you were attracted to a client, was the client also attracted to you?" Most therapists (83%) believed that the attraction had been mutual. Only 9% said that the attraction felt toward a client had never been reciprocated, and 8% indicated that they did not know or were not sure, chi-square (1, N = 452) = 483.1, p < .003. There were no significant sex or age group differences.
Graduate Training and Consultation Seeking
We were interested in learning if the respondents' graduate training programs and internships had provided courses or other structured education about sexual attraction to clients. Over half (55%) indicated that they had received no education about such matters, 24% had received "very little," 12% had received "some," and only 9% believed that sexual attraction issues had been given adequate coverage. Thus, the more extensive the training, the fewer the respondents who had received it, chi-square (1, N = 583) = 274.21, p < .003. No significant sex or age differences related to training experience emerged.
Fifty-seven percent of the respondents reported that they had sought supervision or consultation upon becoming aware of feeling sexually attracted to a client, chi-square (1, N = 483) = 10.47, p < .003. Younger therapists were more likely than older therapists to seek consultation (64% vs. 50%), chi-square (1, N = 483) = 8.60, p < .003. Male and female therapists did not differ significantly on the rate of seeking consultation.
Post hoc tests revealed that those who reported feeling uncomfortable, anxious, or guilty about their sexual attraction (70%) were more likely to seek supervision or consultation than were those who had no associated discomfort (37%), chi-square (1, N = 474) = 49.43, p < .001. Furthermore, those who had at least some graduate training about sexual attraction to clients were more likely to seek consultation (66%) than were those with no such training (49%), chi-square (1, N = 474) = 12.92, p<. 001.
The long-standing absence of systematic research on this topic might give the impression that psychologists—unlike other human beings—are incapable of experiencing sexual attraction to those they serve, or that the phenomenon is at most a strange and regrettable aberration, limited mostly to those relative few who engage in sexual intimacies with their clients
This study presents some initial data providing clear evidence that attraction to clients is a prevalent experience among both male and female psychologists. Our data suggest that this widespread phenomenon is one for which graduate training programs and clinical internships leave psychologists almost entirely unprepared. As discussed in the introduction, inattention to this topic in educational programs may be due partly to the taboo nature of the phenomenon and to the belief that such attraction is dangerous and anti-therapeutic. It may also be the consequence, in part, of the fact that there is virtually no research-based information about the subject, that there is "nothing to teach."
If training programs, by their-behavior and example, suggest that the issue of attraction is to be shunned and that feelings of attraction are to be treated as dangerous and anti-therapeutic, it is not surprising that individual psychologists tend to experience feelings of attraction with wary suspicion and unsettling discomfort. In our survey, more younger psychologists than older psychologists reported such negative feelings, which suggests that whatever efforts training programs have made in the recent past to address these issues have not been fully successful.
An encouraging finding is that 57% of the psychologists sought consultation or supervision when attracted to a client. This is especially true of younger psychologists and those who felt uncomfortable, guilty, or anxious about the attraction. Although seeking help from a colleague may in part reflect the view that attraction is a sign that something has gone wrong with the therapy, such consultation and supervision can give psychologists access to guidance, education, and support in handling their feelings.
Most psychologists (71%) who were sexually attracted to their clients believed that their clients were unaware of the attraction. Thus the phenomenon seems to be one that generally goes unmentioned in the psychotherapy relationship itself. Moreover, the findings suggest that for a substantial group (at least 20%) of the respondents, their attraction to clients not only received inadequate coverage (or no coverage at all) during their graduate training but also went unmentioned to their clients, consultants, or supervisors. Thus, these psychologists seemingly have refrained from talking about the attraction with anyone else, at least within the context of their professional work.
Even though sexual attraction for some psychologists remained unspoken to colleagues and clients, it nevertheless could find expression in the fantasy life and sexual behavior (not involving the client) of a minority of the profession. The age and gender differences are consistent with the research regarding sexual fantasizing in general, which shows higher rates for males and for younger adults (Pope, 1982). It is important to note, however, that the questionnaire item was limited to sexual fantasies occurring during sexual activity with someone else. Thus, the rates of more general sexual fantasizing about clients may be much higher. (For additional data on sexual fantasizing about therapy clients, see Pope, Tabachnick, and Keith-Spiegel, 1987; Pope & Tabachnick, 1993; and Pope, Sonne, and Holroyd, 1993).
Especially in light of the literature from a variety of theoretical orientations emphasizing the clinical usefulness of therapists' fantasies about their clients (see Singer & Pope, 1978), such sexual fantasizing deserves careful research as well as frank acknowledgment in psychology training programs. Geller, Cooley, and Hartley (1981-1982) pioneered a research strategy for systematically exploring the ways in which therapy clients mentally represent their therapists (through fantasy, mental imagery, imagined conversations, etc.). Such a strategy could be adapted to study the ways in which therapists mentally represent the clients to whom they are sexually attracted.
Although 29% of the respondents experiencing sexual attraction to clients engaged in sexual fantasies regarding those clients, a much smaller number engaged in actual sexual intimacies with the clients. The percentages of all respondents (9.4% of men; 2.5% of women) engaging in such intimacies with clients are similar to findings of the first two national surveys of psychologists (Holroyd & Brodsky, 1977; Pope, Levenson, & Schover, 1979). The 8 studies table (shown above) presents summary data from the national studies of sex between psychologists, psychiatrists, or social workers and their clients that have been published in peer-reviewed journals. Pooling the data from the 5,148 participants in these national studies reveals that overall about 4.4% of the therapists report becoming sexually involved with at least one client. The gender differences are significant: about 6.8% of the male therapists and about 1.6% of the female therapists reported engaging in sex with at least one patient. For further analyses involving profession, year of publication, etc., of these national studies, see Pope (2000).
Previous research has suggested that of therapists who become sexually involved with a client, 75% to 80% do so repeatedly; one therapist was reported to have been involved with over 100 clients (Pope & Bouhoutsos, 1986; Pope, 1994; 2000; Pope & Vasquez, 1999). However, in the current study, of those who engaged in sexual intimacies with their clients, 86% did so once or twice, 10% did so between 3 and 10 times, and only one psychologist (female) reported a frequency of over 10 times. Perhaps the courts and regulatory agencies have removed from practice or altered the practices of some psychologists who engaged in extreme and frequent violation of the prohibitions against therapist-client sex. The publicity accompanying such cases, as well as the increased attention to imposing explicit sanctions for such violations, may have deterred or restrained many others.
The current research provides some preliminary information about the clients to whom therapists are sexually attracted. When asked to describe the personal attributes of the clients who elicited the sexual attraction, male and female psychologists did not differ, for the most part, in their responses. However, males, far more than females, mentioned physical characteristics. On the other hand, females far more than males, mentioned that the "successfulness" of their clients was what attracted them sexually. This difference seems an obvious reflection of the sex role stereotypes characteristic of the general culture.
Most respondents believed that sexual attraction to clients had been, at least in some cases, useful or beneficial to the therapy. Men seemed to view sexual attraction to clients as not only more beneficial but also more harmful than did women. Respondents' reports concerning whether clients were aware of the therapists' attraction were significantly related to the belief that attraction was harmful. Although the association does not constitute causation, it is still tempting to speculate that the therapists' responses reflected a belief that what clients do not know will not hurt them.
Why do therapists refrain from acting out their attraction to clients? It was gratifying to note that the major reasons seemed to express professional values, a regard for the client's welfare, or personal values compatible with professional standards. Fears of negative consequences and self-serving reasons were mentioned, though less frequently.
Therapist Gender and Sexual Attraction
That sexual attraction to clients is a common experience among female as well as male psychologists is a finding worth emphasizing in several respects. First, the relevant countertransference literature (as well as the therapist-client sexual intimacy literature) often uses the pronoun he when referring to the therapist and the pronoun she when referring to the client in instances in which there are no specific antecedents. Some of the material quoted in the introduction reveals this trend (for example, Freud, 1915/1963; Greenson, 1967; Kaplan, 1977; Ruesch, 1961). This usage is understandable (most therapists are men; most clients are women) but nonetheless is misleading. It implies (incorrectly) that the only therapists who experience sexual attraction to clients are men and that the only clients to whom therapists are attracted are women. It may serve to place an even greater taboo upon the sexual attraction a female psychologist may experience toward her clients and may thus cause or amplify the anxiety, discomfort, or guilt that accompanies this attraction.
Second, the early widely publicized malpractice suits concerning therapist-client sexual intimacy involved male therapists and, as a consequence, the discussions of this issue focused almost exclusively on male therapists. However, factors that initially seemed to inhibit the filing of such suits against female therapists later became less effective (Turkington, 1984; Pope & Bouhoutsos, 1986; Pope, 1994), and the group of therapists who sexually exploit their clients is now seen to include female as well as male psychologists.
Third, the findings of the current study suggest that therapist gender, as a variable, may be systematically associated with the various aspects of attraction to clients. For example, whereas the percentage of therapists attracted exclusively to their own sex was 0.6% for men and 2.4% for women, 23% of the female therapists as compared to 13% of the male therapists reported sexual attraction to both male and female clients.
Further research is needed to examine the validity, meaning, and implications of such findings. For the research and associated literature to be truly illuminating and useful, it must be acknowledged that the sexual exploitation of clients and the distinctly different phenomenon of sexual attraction to clients are not limited to male therapists. Furthermore, it should be noted that attraction to clients, though a common experience, is apparently not universal: Five percent of the men and 24% of the women in this study reported no sexual attraction to their clients.
The data suggest that personal ethics and a regard for client welfare are more compelling than fear of negative consequences as reasons for refraining from sexual intimacies with clients. Therefore, efforts to rely predominantly on a system of imposing external sanctions for such behavior may be much less effective in preventing violations than an approach focused on formal training, both in graduate institutions and in continuing education programs.
To be successful, a training approach must first of all acknowledge the value of honest, serious discussions about therapists' attraction to clients. Therapists and therapists in training must be acknowledged as fully human, as capable of feeling sexual attraction to those to whom they provide professional services. The taboo must be lifted.
Second, addressing the issue must not be limited to a one-hour lecture, set apart from the "normal" curriculum. Education regarding this topic can be an appropriate part of almost all clinical and professional course-work and training. Similarly, the topic should be reflected in textbooks and other teaching materials and techniques (see, e.g., the APA book Sexual Feelings in Psychotherapy: Explorations for Therapists and Therapists-in-Training).
Third, the material presented should include information based on systematic research. The virtual absence of research on the topic of therapists' attraction to their clients lends more force and urgency to the standard and obligatory call for further research. The current study of therapists' attraction to clients, along with the initial research concerning therapist-client sexual intimacy and student-teacher sexual intimacy, represents an initial attempt to gather basic data in previously unexplored areas.
Fourth, the phenomenon of therapist-client sexual intimacy must be clearly differentiated from the experience of sexual attraction to clients. The latter seems to suffer from guilt by association (Pope, Sonne, & Holroyd, 1993), and the general failure to discuss the experience openly does little to clarify the situation.
Fifth, educational programs must provide a safe environment in which therapists in training can acknowledge, explore, and discuss feelings of sexual attraction. If students find or suspect that their teachers are critical and rejecting of such feelings and that such feelings are treated as the sign of an impaired or erring therapist, then effective education is unlikely.
Even if sexual attraction to clients is not viewed as a therapeutic offense, the acknowledgment of the attraction—as in the case of Searles (1959/1965) mentioned in the introduction—is often associated with feelings of vulnerability and trepidation. Students may fear that their disclosures of sexual attraction will lead to their educators asking intrusive questions about their personal lives, making insensitively flip or humorous comments, failing to maintain appropriate confidentiality (i.e., gossiping), or trying to satisfy their voyeuristic tendencies through titillating conversation.
Students need to feel that discussion of their sexual feelings will not be taken as seductive or provocative or as inviting or legitimizing a sexualized relationship with their educators. As discussed in the introduction, sexual intimacies between teachers or supervisors and their students, most often in the context of a working relationship, are not uncommon. Educators must display the same frankness, honesty, and integrity regarding sexual attraction that they expect their students to emulate. Psychologists need to acknowledge that they may feel sexual attraction to their students as well as to their clients. They need to establish with clarity and maintain with consistency unambiguous ethical and professional standards regarding appropriate and inappropriate handling of these feelings.
[Note: Some references and text have been updated since the publication of the original article.]
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- Licensing Disciplinary Actions for Psychologists Who Have Been Sexually Involved with a Client
- National study of of the ethics of psychologists as educators
- Ethics in Psychotherapy and Counseling (5th ed.)
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