Therapist-Patient Sex as Sex Abuse:
Six Scientific, Professional, and Practical Dilemmas in Addressing Victimization and Rehabilitation
ABSTRACT: Psychology, like other mental health professions, has experienced difficulty addressing the issue of therapist-patient sexual intimacies vigorously, carefully, and effectively. Six fundamental challenges, based on frequently made comparisons of therapist-patient sex to incest and rape, are identified as crucial in addressing forms of sex abuse in which perpetrators are predominantly male and victims are predominantly female: (a) acknowledging the scope of the phenomenon, (b) affirming the notion and the mechanisms of accountability, (c) assessing the validity of allegations, (d) evaluating the nature and validity of research evidence, (e) overcoming perpetrator stereotypes and inclinations to collude with or to enable sex offenders, and (f) confronting the notion of victim responsibility.
One of the first, most persistent psychologists urging the profession to confront and eliminate therapists' sexual abuse of patients was Keith-Spiegel (1977), who noted the ineffectiveness of appealing to perpetrators and potential perpetrators on the basis of a professional ethic of avoiding harm to patients or an ethic of refraining from sexual abuse of women. She reframed the issue to appeal more to self-interest, providing "ten reasons why [sex with clients] is a very stupid thing to do." Her focus was "not on the devastation that may result for the client ... but on what ensues for the psychologist" (p. 1).
Despite such concern, however, sexual abuse of patients continues. The thesis of my article is that psychology's difficulties confronting the sexual abuse of (mostly female) patients by (mostly male) therapists parallel earlier professional attempts to address forms of sexual abuse, such as rape and incest, in which the perpetrators are predominantly male and the victims are predominantly female. This parallel implies that effectively addressing sex abuse requires a careful, informed, and reasoned response to at least six fundamental challenges, which are discussed in the following sections.
Three considerations are important in providing a context for the following discussion. First, comparing therapist-patient sexual intimacies with other forms of sex abuse is by no means an original idea; numerous clinicians and researchers have analyzed the various ways (e.g, in terms of dynamics, characteristics of perpetrators, uses of power, lack of genuine consent, and consequences for victims) in which sexual intimacies with patients are similar to rape and incest (e.g., Bailey, 1978; Barnhouse, 1978; Bates & Brodsky, 1989; Borys, 1988; Burgess, 1981; Chesler, 1972; Connel & Wilson, 1974; Dahlberg, 1970; Finkelhor, 1984 ; Freud, 1915/1983; Gabbard, 1989; Gilbert & Scher, 1989; Herman, Gartrell, Olarte, Feldstein, & Localio, 1987; Kardener, 1974; Kavoussi & Becker, 1987; Maltz & Holman, 1984; Marmor, 1972; Masters & Johnson, 1976; Pope & Bouhoutsos, 1986; Redlich, 1977; Russell, 1986; Saul, 1962; Searles, 1959; Siassi & Thomas, 1973; A. A. Stone, 1990; L. G. Stone, 1980; M. Stone, 1976).
Second, it is possible for some therapists to argue from a variety of perspectives that therapist-patient sexual intimacies are in no way abusive (e.g., that sexual intimacies do not usually cause great harm to patients and are generally inconsequential or beneficial; that such intimacies do not constitute an abuse of trust, power, prerogative, responsibility, or the therapeutic relationship). Even (or especially) in light of such arguments, it may be heuristically useful to examine ways in which professional responses to therapist-patient sex may be similar to responses to rape and incest. All three phenomena present us with difficult dilemmas. The response to these dilemmas may play a crucial role in the continuing development of our profession's scientific integrity and ethical character.
Third, it is crucial to emphasize that psychologists do not--at least in light of the most recent research--engage in such abuse at higher rates than do members of the other mental health professions. In the most recent national survey of 4,800 therapists, Borys and Pope (1989) found that psychiatrists, psychologists, and clinical social workers engaged in sexual intimacies with their patients at equivalent rates.
Acknowledging the Scope of the Phenomenon
The first challenge is to acknowledge the existence and scope of the behavior. Historically, forms of sexual abuse such as rape and incest have, until relatively recently, received little attention and were thought to involve very few people (Courtois, 1988 ; Estrich, 1987; Herman, 1981; National Institute of Law Enforcement and Criminal Justice, 1975; Russell, 1986; C. E. Walker, Bonner & Kaufman, 1988). Less than 40 years ago, for example, a scholarly volume stated that there were about one or two cases of incest each year for each million U.S. citizens (Weinberg, 1955). More recently, the Comprehensive Textbook of Psychiatry placed the incidence rate at between 1.1 and 1.9 per million ( Henderson, 1975). Likewise, rape was generally ignored or neglected -- Amir (1971) was unable to find even one book devoted exclusively to the topic -- and as late as the early 1970s, rape accusations were generally viewed as "lies or fantasies" (Estrich, 1987, p. 43).
Charges of sex abuse were thus generally attributed to an assumed innate female tendency to make false allegations of a sexual nature against innocent men. It is possible that this attribution gained popularity from Freud's renunciation of his "seduction theory". "When girls who bring forward this event [incest] in the story of their childhood fairly regularly introduce the father as the seducer, neither the phantastic character of this accusation nor the motive actuating it can be doubted" (Freud, 1924/1952, p. 379). The assumed motive is female sexuality and a female desire for an incestuous relationship with the father (p. 379).
The 1970 edition of Wigmore's authoritative text on legal evidence exemplifies the degree to which the legal and psychiatric professions accepted the view that almost all charges of sex abuse reflect an inherent female tendency both to make false accusations and to fantasize about being raped. Wigmore stated authoritatively that
chastity may have a direct connection with veracity, viz. when a woman or young girl testifies as complainant against a man charged with a sexual crime-rape, rape under age, seduction, assault. Modern psychiatrists have amply studied ... girls and women coming before the courts in all sorts of cases. Their psychic complexes are multifarious, distorted partly by inherent defects, partly by diseased derangements or abnormal instincts, partly by bad social environment, partly by temporary physiological or emotional conditions.... The unchaste (let us call it) mentality finds incidental but direct expression in the narration of imaginary sex incidents of which the narrator is the heroine or the victim... . No judge should ever let a sex offense go to the jury unless the female complainant's social history and mental makeup have been examined and testified to by a qualified physician.... The reason I think that rape in particular belongs in this category is one well known to psychologists, namely, that fantasies of being raped are exceedingly common in women, indeed one may almost say that they are probably universal. (Wigmore, 1934/1970, pp. 745-746)
The sexual abuse of patients similarly received little attention until the recent past. Although the prohibition has been found in sources as diverse as the 2, 500-year-old Hippocratic Oath and the even earlier code of the Nigerian healing arts (Brodsky, 1989), the professional literature failed, for the most part, to address even the possibility that a number of professionals were violating this ancient prohibition (Keith-Spiegel & Koocher, 1985; Pope & Bouhoutsos, 1986). As late as 1977, Davidson could term sexual intimacies with patients the "problem with no name."
At times, there has been active resistance to collecting or publishing data showing the scope and consequences of such abuse. More than 25 years ago, H. Greenwald (cited by Shepard, 1971) tried to encourage systematic study of therapist-patient sexual intimacies:
I just raised the questions ... intending, as a clinical psychologist, that it be studied like any other phenomenon. And just for raising the question, some members circulated a petition that I should be expelled from the Psychological Association. (p. 2)
In the late 1960s, B. Forer, having obtained the approval of the Los Angeles County Psychological Association and the Los Angeles Society of Clinical Psychologists to survey their memberships, undertook the first systematic study of the phenomenon in the United States. To the dismay of both organizations, his findings indicated a relatively high rate of sexual intimacies between members and their patients. On October 28, 1968, having reviewed his research data with organizational leadership, the Board of Directors decided to prohibit disclosing the findings either at professional conventions or through journal publication (an interesting decision in light of the mandate of the American Psychological Association's [APA's] Ethical Principle 1 a that psychologists never suppress data disconfirming their favored hypotheses; APA, 1981 ), maintaining that it was "not in the best interests of psychology to present it publicly" (B. Forer, personal communication, November 1984; see also Forer, 1980).
Active resistance to disclosure of studies suggesting that therapists have been sexually abusing their patients was by no means limited to the psychology profession. In the introduction to his article "Sexual Contact Between Patient and Therapist, " a prominent psychiatrist noted "I have had trouble getting this paper accepted by larger organizations where I had less, but still not inconsiderable, influence. I was told that it was too controversial" (Dahlberg, 970, p. 107). Gechtman (1989) discussed evidence that resistance to the publication of such data still remains exceptionally strong among social work organizations.
The first article drawing inferences from systematically collected data regarding the phenomenon of therapist-patient sexual intimacies in psychology appeared in American Psychologist in 1971. After analyzing 10 years of insurance carrier data regarding malpractice complaints filed against psychologists, Brownfain (1971) concluded
that the greatest number of [all malpractice] actions are brought by women who lead lives of very quiet desperation, who form close attachments to their therapists, who feel rejected or spurned when they discover that relations are maintained on a formal and professional level, and who then react with allegations of sexual improprieties. (p. 651)
He mentioned no case during this 10-year period in which a patient's claims of sexual intimacies with her therapist were considered to be truthful.
Two years later, the American Journal of Psychiatry published data, based on a survey of the male members of the Los Angeles County Medical Society, suggesting that at least some therapists (about 10% of the psychiatrists) had in fact engaged in sex with one or more patients (Kardener, Fuller, & Mensch, 1973). The format of this survey formed the basis for the first national incidence study of therapist-patient sex, a study undertaken by two psychologists (Holroyd & Brodsky, 1977). They found, on the basis of a 70% return rate, that 11% of the male therapists and 2% of the female therapists reported engaging in erotic contact with at least one patient and that 80% of those therapists did so with more than one patient. Their work constituted a landmark in the profession's acknowledgment that a number of therapists were actually engaging in sexual intimacies with their patients. Numerous research studies followed (for reviews of this literature, see Gabbard, 1989 ; Pope, 1990; Pope & Bouhoutsos, 1986). Research and theory were brought to bear on the fact that the intimacies were frequently initiated after termination, a factor that, like initiating the intimacies outside of the office or only with patients who were "mature, " made them no less abusive or harmful (Brown, 1988; Ethics Committee of the APA, 1988; Gabbard & Pope, 1989; Pope, 1988; Vasquez, in press). The sexual abuse of patients could no longer continue as the "problem with no name", it is increasingly difficult to dismiss virtually all accusations as groundless, as the expression of individual psychopathology or of some innate female tendency to make false sex charges against men. Like rape, incest, and other forms of sexual abuse, sexual abuse of patients is no longer invisible.
Having acknowledged that some therapists have been engaging in sexual intimacies with people who have come to them for help, we must determine the degree to which we are willing to affirm and support actively and effectively the long-standing prohibition against the practice and to hold ourselves genuinely accountable for violating the prohibition. It has been suggested that one of the primary reasons that health care professions have experienced such difficulty responding realistically and effectively to rape and incest is that the populations both of perpetrators and of health care professionals have historically been predominantly male (e.g., Masson, 1986). The male professional's sense of identification with the male perpetrator (intensified because both roles-health care professional and sex abuse perpetrator-involve being the more powerful member of a private dyad) may, according to this view, elicit the professional's collusion in exonerating the perpetrator's accountability for his acts and/or enabling the perpetrator to continue the abuse (e.g,, through unsubstantiated claims of "rehabilitation"). Thus the professional is placing an aspect of (perceived) self-interest (based on identification with the perpetrator) above the interests or needs of the victim.
Health care professions, like any professions, struggle constantly with the conflict between "self-interests" (often termed "guild interests") and the ethic that professionals will scrupulously act in ways that safeguard the safety of patients. In an analysis of issues related to the withholding of care from people suffering from AIDS, Pellegrino (1987), of the Kennedy Institute of Ethics, wrote
Nothing more exposes a physician's true ethics than the way he or she balances his or her own interests against those of the patient. Whether the physician is refusing care for patients with the acquired immunodeficiency syndrome (AIDS) for fear of contagion ... or withdrawing from emergency department service for fear of malpractice suits, striking for better pay or fees, or earning a gatekeeper's bonus by blocking access to medical care, the question raised is the same. (p. 1939)
Pellegrino argued that it is various aspects of a commitment to forgo certain self-interests in order to protect or serve the welfare of patients "that distinguish medicine from business and most other careers or forms of livelihood" (p. 1939). Medicine's commitment to such a professional ethic may be in the process of erosion. The president of the Association of American Medical Colleges, for example, noted that "studies show that medical students are lenient towards dishonesty in education and practice" (Petersdorf, 1989, p. 119). Students' lenient attitudes toward fraudulent practices that benefit the professional at the expense of the patient may be influenced by the less-than-vigorous systems of discipline and accountability in which physicians play an active role. An extensive study, for example, concluded, "Physician discipline in California is a code blue emergency. The system cannot and does not protect Californians from incompetent medical practice" (Center for Public Interest Law, 1989, p. 1). For further examples and discussion of professional review boards, see Sonne and Pope (in press) .
The resistance to accountability and resultant erosion of effective monitoring of compliance with professional standards may be operative in the area of therapist-patient sexual intimacies. The American Psychiatric Association, for example, has been criticized by some members for its failure to address this issue in good faith. Gartrell, a former professor at Harvard who was principal investigator in the first national study of sexual intimacies between psychiatrists and their patients (Gartrell, Herman, Olarte, Feldstein, & Localio, 1986, 1987 , 1989), resigned her membership in the American Psychiatric Association in protest of what she considered their failure to act effectively to maintain the prohibition, to protect patients, and to hold perpetrators accountable (personal communication, November 14, 1989). Similarly, Gay, a member of the American Psychiatric Association who has been deeply involved in efforts to hold therapists accountable for sexual abuse of their patients concluded, "I used to believe the [American Psychiatric Association]... . But they want to have one image publicly, then the way they act supports a completely different conclusion. I think the [American Psychiatric Association] is not part of the solution; I think the [American Psychiatric Association] is part of the problem" (Terwilliger, 1989c, p. F2). A former president of the American Psychiatric Association suggests that economic interests may heavily influence responses to accountability for victimization. Observing that liability insurance has traditionally served the dual purpose of protecting practitioners economically and compensating patients victimized by malpractice, A. A. Stone (1990) maintained that it is hard to justify the policy limits on payment to the (mostly female) victims of sexual exploitation by therapists. He noted that the economic selfinterest of these limits is "often presented with the windowdressing argument" (p. 25) that the perpetrators should not be protected. This conflict of interest, according to A. A. Stone, seems to lead to the placing of greater weight on economic self-interest (i.e., keeping malpractice premiums used to cover the costs of damages from becoming too expensive for therapists) than on the profession's concern for victims. "The point is that the American Psychiatric Association will continue to have an economic interest in defending victimizing doctors who have committed the most egregious sexual exploitation if only to limit the amount of damages awarded" (p. 26). If psychologists are to create an effective method for eliminating the sexual abuse of patients, the possible tension between individual and collective self-interest and the safety of patients must be confronted forthrightly.
However, there is a second, related factor that may make it even more difficult to institute effective mechanisms of accountability. Many of us may be exceptionally wary of any efforts to monitor or regulate our actions, even (or especially) if such efforts are made by our own professional association. The history of the APA is interesting in this regard. The APA held its first meeting in 1892, ratified its constitution in 1894, and became incorporated in 1925. Yet it was not until the late 1930s that it was able to create an ethics committee in an attempt to ensure high standards among its membership. Prior attempts to regulate the practice of professional psychology included three separate efforts in the 1920s to establish a system of certifying psychologists performing clinical services (Fernberger, 1932). The third attempt ended when fewer than 30 psychologists could be persuaded to apply for certification-even when the application fee was drastically reduced from $35 to $5. The Committee on Certifications issued a report suggesting that by virtue of the scientific framework of the profession, psychologists, "while commonly energetic and at times heroic in the pursuit of personal aims and ideals, seldom exhibit the capacity for resolute common action which [would be necessary to maintain adequate standards despite] the energy and resources which would be mustered by [colleagues] charged with misconduct" (Fernberger, 1932, p. 50).
Accusations and Guilt; Denials and Innocence
A third pitfall can be anticipated from a study of responses to other forms of sex abuse: the danger of judging accusations or denials of therapist-patient sex to be always true or always false. Each accusation and denial must be painstakingly evaluated on an individual basis. This principle would seem so obviously self-evident as to be at best an innocuous truism. Yet the history of professional reactions to sexual abuse indicate how easily this principle is violated.
Perhaps influenced by Freud's recantation of his seduction theory, many professionals and courts alike seemed to accept the premise that children's allegations of incest or other forms of sexual abuse by adults were virtually always invalid (Masson, 1984; Miller, 1984 ; Rush, 1980). Other professionals, however, maintained that "young children never make up specific sexual stories or lie about who molested them" (Siegel, 1989, p. 29).
The phenomenon of sexual intimacies between therapists and patients may provoke similar tendencies to prejudge, especially in light of the issues involved and the tendency of sex abuse accusations to elicit intense emotional reactions. All of us must become aware of the ways in which our careful, unbiased evaluation of individual accusations and denials may be distorted by strong desires to protect innocent colleagues (and perhaps also those who engage in sexual abuse) from accusations, from involvement in formal hearings, and from sanctions, and to protect patients not only from victimization but also from revictimization that comes from having valid complaints discounted. Psychologists serving as expert witnesses in court settings or as members of ethics committees, licensing boards, hospital peer review committees, or other deliberative bodies have an especially significant responsibility to ensure that they render a thoroughly honest, truly professional judgment. Great harm is done to a practitioner innocent of any sexual involvement with a patient when a false accusation is, through carelessness, bias, or other factors, formally judged to be true. Great harm is done to both current and future victims of an actual perpetrator when a victim's accusations are unfairly dismissed, discounted, or minimized. Psychologists must be particularly careful when using standardized tests to evaluate alleged perpetrators or alleged victims to ensure that the test has been adequately normed and validated for the relevant population and for the use to which it is being put, especially in light of evidence that failure to do so when using such tests as the Minnesota Multiphasic Personality Inventory (MMPI) can result in serious errors (Butcher & Pope, 1990; Pope & Bouhoutsos, 1986; Pope, Butcher, & Seelen, 2000).
The Nature of Information, Evidence, and Knowledge
A fourth challenge to psychology and allied health professions is in confronting the question, What forms of information or research evidence regarding sexual intimacies between therapists and patients will be considered persuasive (Pope, 1986)?
What we will accept as evidence regarding such intimacies depends in part on our epistemological assumptions. Numerous writers have explored the nature, validity, and implications of diverse scientific methods, with considerable attention to the social and behavioral sciences (e.g., Adair, 1973; Ash & Woodward, 1988; Bannister, 1987; Barber, 1976; Child, 1973; Cook & Campbell, 1979; Flanagan, 1988; Hilgard, 1987; Kuhn, 1962/1970, 1977; Manicas, 1987; Piaget, 1970/1977; Plutchik, 1968; Polanyi, 1958; Popper, 1935/1959; Rosaldo, 1989; Rosenthal & Rosnow, 1975; Rychlak, 1977; Sarason, 1988; Staats, 1981; Ziman, 1968). In his survey, Kimble (1984) found a diversity of views within the field of psychology. An extreme view holds that the only acceptable psychological method is that employed by a few (not all) of the natural sciences: Only when quantifiable variables can be isolated, randomly assigned, and manipulated in a controlled environment is the evidence acceptable. According to this view, paleontology, anthropology, ethology, and astronomy are not genuine sciences in that they rest primarily on careful and systematic observation of naturally occurring phenomena that do not permit substantial experimentation with completely isolated and randomly assigned variables in a controlled environment. This appears to be a minority view. M. Levine (1974) noted and endorsed the shift from the stance "that all problems are better handled with the logic of experimental design and statistical inference" to a general recognition that the real dilemma for psychology was to "distinguish between problems that can be studied by experimentation and those that cannot" (p. 664). A decade later, Wittig's (1985) review of the field led her to conclude,
Most researchers in psychology recognize that exclusive reliance on the methods of the natural sciences does not provide a proper basis for psychology. The challenge is to gain consensus concerning the strength of the conclusion to be drawn, given the power of the techniques employed. (p. 805)
Whatever the customary epistemological stance may be, any association that finds itself accused of causing harm to the public (e.g., that members of mental health professions are sexually abusing their patients, are not acting vigorously and effectively to prevent this abuse, and are enabling perpetrators to resume practice with vulnerable patients on the basis of unvalidated claims of rehabilitation) may tend to defend itself by pointing out that any evidence of harm does not meet sufficiently rigorous scientific standards. The tobacco industry, for example, correctly points out that the evidence supporting the hypothesis that smoking harms or at least endangers humans does not meet certain scientific criteria (see, e.g., Patterson, 1987): (a) the animal studies-in which isolated variables are randomly assigned in a controlled environment (e.g., precise control of exactly how much smoke is inhaled over specified temporal intervals, of all facets of diet that might interact with smoking effects, of all environmental variables, of relevant genetic predispositions)-cannot be assumed to have direct implications for another species (i.e., humans), and (b) none of the human studies involve random assignment to smoking and nonsmoking groups or adequate isolation of variables; for example, all smokers are self-selected (thus introducing a bias of indeterminable magnitude), and those smokers who do volunteer for studies may differ in significant ways from those smokers who decline to participate.
Interestingly, when APA acquired Psychology Today, a venture hailed as "a far-sighted and sagacious move in the direction of social responsiveness [and] primary prevention" (Salameh, 1984, p. 4), it became the only health profession to generate considerable revenue by running advertisements that urged consumers to use tobacco products, although certain other types of advertisement were unacceptable. The APA Board of Directors unanimously agreed to issue a public policy statement in which the association did not characterize smoking as harmful (see, for example, the Surgeon General's Warning on cigarette packets that "Smoking causes lung cancer, heart disease, emphysema, and may complicate pregnancy") but rather adopted more scientifically conservative language, concordant with the tobacco industry's position, to assert that cigarettes are one of a number of "products considered by some to be hazardous" (Advertising policy adopted for magazine, " 1983, p. 2). It is crucial that we maintain an active awareness of the degree to which individual or collective defensiveness may be biasing our evaluations of whether certain actions actually cause harm.
The issue of what constitutes acceptable evidence is accentuated in the area of sexual abuse. As the professions began to overcome their resistance to acknowledging such phenomena, some professional authorities assumed that the activities labeled sexual abuse tended to be neither more nor less harmful than other forms of human sexual interactions. Kinsey, Pomeroy, Martin, and Gabbard (1953), for example, in their landmark text, Sexual Behavior in the Human Female, did not follow up on the fact that 80% of the girls who had engaged in sexual intimacies with adults reported that they were "emotionally upset and frightened." The researchers viewed such relationships as essentially no different from those sexual relationships between adults in which one person has not assumed responsibilities relating to the welfare of the other, could not be considered to be more powerful than the other, and so forth. Any human sexual relationships, according to Kinsey and his colleagues, might produce a little upset; incest was not inherently different. Any general harm could be reasonably attributed only to outmoded cultural or professional biases against such relationships:
It is difficult to understand why a child, except for its cultural conditioning, should be disturbed at having its genitalia touched, or disturbed at seeing the genitalia of other persons, or disturbed at even more specific sex contacts.... Some of the more experienced students of juvenile problems have come to believe that the emotional reactions of parents, police officers, and other adults who discover that the child has had such a contact, may disturb the child more seriously than the sexual contacts themselves. (p. 121)
Those who assert that incest is no more generally harmful than sexual liaisons between adults in which one person has not assumed responsibilities relating to the welfare of the other, could not be considered to be in a more powerful position than the other, and so forth argue that fatally flawed research is being misinterpreted by people imbued with outmoded cultural prejudices. They compare incestuous activity to a private, self-initiated, and completely solitary sexual activity (which thus precludes consideration of issues of power or trust with a second party, fiduciary concerns, etc.). Herman (1981) noted the tendency of what she termed the "pro-incest school of thought" to use this comparison to masturbation. As Ramey (1979), a widely quoted sociologist, wrote, "We are roughly in the same position today regarding incest as we were a hundred years ago with respect to our fear of masturbation" (p. 1). Henderson (1983) likewise decried what he viewed as the unjustified prejudice against both masturbation and sexual intimacies between adults and children within a family, and quoted approvingly D. P. Orr's dismissal of any evidence to date: "The studies used to support allegations that sexual abuse of children is damaging are biased and selected for children already identified as disturbed" (p. 38).
Some professionals, though rejecting any evidence of possible harm, may accept evidence of possible benefits. For example, in the chapter on "Incest" in the Comprehensive Textbook of Psychiatry, Henderson (1975) called attention to such methodological problems in the research as "unfortunate sampling procedures in the study designs" and, though unable to find adequate evidence of general harm, was able to conclude,
The father-daughter liaison satisfies instinctual drives in a setting where mutual alliance with an omnipotent adult condones the transgression. Moreover, the act offers an opportunity to test in reality an infantile fantasy whose consequences are found to be gratifying and pleasurable. It has even been suggested that the ego's capacity for sublimation is favored by the pleasure afforded by incest and that such incestuous activity diminishes the subject's chance of psychosis and allows a better adjustment to the external world. There is often found to be little deleterious influence on the subsequent personality of the incestuous daughter. One study found the vast majority to be none the worse for the experience.... (p. 1537)
Likewise, Karl Menninger, addressing the issue of sexual activity between children and adults, once noted that "when the experience actually stimulates the child erotically, it would appear ... that it may favor rather than inhibit the development of social capabilities and mental health in the so-called victims" (cited by Dziech & Schudson, 1989, p. 8). Similarly, D. Thiessen's paper, "Rape as a Reproductive Strategy, " at the annual meeting of the APA in 1983, prompted consideration of whether rape might have certain benefits for women as a reproductive strategy. He asserted that "patterns of rape seem to follow normal correlates of consenting adults" and that such commonalities suggest that rape may possess "sexual and reproductive facets geared toward the reproductive facility of women" (quoted by Cunningham, 1983, p. 22).
In the area of sexual intimacies between therapists and persons with whom they have developed a professional, fiduciary relationship, it is crucial to confront realistically the nature of the research. For example, researchers have examined the effects of abuse on patients who did not return to a subsequent therapy as well as on those who did, have compared patients who were subjected to abuse by a prior therapist with matched groups of patients who were not victimized, and have explored the sequelae as evaluated variously by the patients themselves, by subsequent therapists, and by independent clinicians through methods including observation, clinical interviews, and standardized psychological testing (Belote, 1974; Bouhoutsos, Holroyd, Lerman, Forer, & Greenberg, 1983; Brown, 1988; Butler, 1975; Chesler, 1972; Durre, 1980; Feldman-Summers, 1989; Feldman-Summers & Jones, 1984; Sonne, 1989; Sonne, Meyer, Borys & Marshall, 1985; L. G. Stone, 1980; Vinson, 1984). Yet some might still argue that because it is impossible to assign subjects randomly, to isolate and control all variables, and so forth, researchers cannot determine whether therapist-patient sex, rape, incest, or other forms of abuse are generally harmful or are actually more likely to be enjoyable and beneficial to the (predominantly female) individuals who experience them and that attempts to answer such questions must rest solely on transient cultural prejudices rather than on acceptable scientific evidence. Riskin (1979) maintained that researchers will find out whether sexual intimacies with patients are generally harmful or beneficial only if they conduct experiments on patients in which therapist-patient sexual activity is the independent variable; he recommended that patients be randomly assigned to sexual and nonsexual treatment conditions.
If we do not reject all evidence concerning sexual abuse as failing to meet scientific criteria, we must take seriously the limitations and qualifications emphasized by reports of the research. For example, Holroyd and Brodsky (1977) stressed that it is "crucial to consider reliability issues" (p. 848); Bouhoutsos et al. (1983) emphasized that "the meaningfulness of these data ... must be evaluated in the light of our sample characteristics... . We do not know the effects for patients who did not return to therapy" (p. 192); and Borys and Pope (1989) underscored six validity issues, one of which concerns a cluster of issues involved in their approach to data interpretation, including
problems in sample selection, the potential similarities and differences between responders and nonresponders in survey studies, issues in scaling and statistical analysis, [and] the qualified nature of inferences drawn from specific findings. (p. 289)
It is only when such qualifications regarding validity and reliability are carefully taken into account that what Wittig (1985) termed the "power of the techniques" can truly emerge and the difficult, often frustrating struggle to learn from diverse investigations--each adding a piece of the puzzle--can proceed.
The Nature of Perpetrators and the Questionable Nature and Efficacy of Rehabilitation
A prevalent societal and professional misconception about rapists and incest perpetrators has been (at least generally) laid to rest: that they are predominantly the least educated, least respected, most marginal members of the community (Barnard, Fuller, Robbins, & Shaw, 1989; Estrich, 1987). Lanyon (1986), for example, noted in his review of the literature that
Most prominent is the stereotype that child molesters are socially marginal persons or "dirty old men." Indeed, the child molester is most commonly a respectable, otherwise law-abiding person, who may escape detection for exactly that reason. (p. 177)
Similarly, there emerged a stereotype (and, regrettably, it may have been cultivated by an embarrassed profession): that therapists who sexually abused patients were those marginal members of the profession who were most poorly trained. Such stereotypes served as the basis for numerous optimistic rehabilitation efforts that generally involved some combination of (a) education (e.g., an ethics tutorial, continuing case consultation or supervision, and individualized courses in issues such as countertransference, boundary management, and sexual material in psychotherapy), and (b) intensive, long-term psychotherapy lasting several years. Unfortunately, neither education nor psychotherapy has shown any evidence in published research studies of inhibiting sexual abuse of patients, and according to some studies, they actually appear to be positively associated with tendencies to abuse (Pope, 1990). For example, a national study of psychiatrists revealed that "offenders were more likely [than nonoffenders] ... to have completed an accredited residency ..., and to have undergone personal psychotherapy or psychoanalysis" (Gartrell et al., 1989, p. 7). Similarly, a national study of social workers revealed that personal therapy was not associated with lower rates of sexually abusing patients and that perpetrators were more likely than nonperpetrators to have fulfilled additional requirements for inclusion into the National Academy of Certified Social Workers (Gechtman, 1989). A study of knowledgeable, well-trained, and successful psychologists revealed a higher rate of sexual abuse of patients than that found in the more general surveys of psychologists (Pope & Bajt, 1988). It is worth considering whether high educational accomplishment and professional status may not only, in accordance with Lanyon's (1986) speculation, help perpetrators to avoid detection but also contribute more generally to some psychologists' sense that they and their colleagues are (or should be) above the law and beyond accountability to which other less entitled citizens are subject, that they are too elite and knowledgeable to be subject to such restraints, and that even to call their behavior formally into question is an affront and may be unethical. For example, in one study of exceptionally accomplished and respected senior psychologists (Pope & Bajt, 1988), 9% of those who reported intentionally breaking formal legal and ethical standards revealed that the standard they violated was the prohibition against sex with a patient and that this violation was an act of professional responsibility (i.e., that they engaged in sex with the client to promote "client welfare"). Another study of psychologists (Pope, Tabachnick, & Keith-Spiegel, 1987) revealed that 2.4% believed that to formally report a colleague's harmful behavior under any circumstances was inherently unethical behavior on the part of the psychologist filing the complaint; an additional 12.8% believed that reporting such behavior was ethical only under rare circumstances.
Civil disobedience (a term coined by Thoreau, 1949/1960) was developed as a concept of ensuring accountability through voluntary acceptance of the penalties for breaking laws considered to be unjust and oppressive as a means of bringing about social change (Gandhi, 1948; King, 1986; Plato, 1956a, 1956b; Thoreau, 1849/1960; Tolstoi, 1894/1951). For psychologists to arrogate this term to avoid accountability for engaging in sexual abuse, keeping secret the sexual abuse of others, committing perjury, faking professional credentials and obtaining expensive gifts from clients seems, at best, misguided (see Pope & Bajt, 1988).
Sexually abusive psychotherapists cannot be dismissed as the most marginal members of the profession. They are well represented among the most prominent and respected mental health professionals. Cases involving therapists publicly reported to have engaged in sexual behaviors with their patients have included those who have served as faculty at the most prestigious universities (including those with APA-approved training programs), psychology licensing board chair, state psychological association ethics committee chair, psychoanalytic training institute director, state psychiatric association president, state association of marriage and family therapists president, prominent media psychologist, chief psychiatrist at a prominent psychiatric hospital, and chief psychiatrist at a state correctional facility ("APA's Ethics Procedures Upheld," 1985; Bass, 1989; Bloom, 1989; Colorado State Board of Examiners, 1988; Jalon, 1985; Matheson, 1984, 1985; Pugh, 1988; "The Resignation of ___ ___," 1990; Smith, 1984). Bates and Brodsky (1989) described how one psychologist gained publicity by reporting a "nationwide survey" based on the conceptualization that sexually abusive therapists were in fact "impaired professionals", the survey findings, which received newspaper coverage, supported efforts to "rehabilitate" these professionals. The psychologist also made a presentation on the subject of rehabilitating perpetrators at an annual meeting of the APA. The general public and the professional community, however, were probably not aware that this psychologist had been engaging in therapist-patient sexual intimacies and, several years after the APA presentation, pleaded guilty to a sex abuse charge (see Bates & Brodsky, 1989).
The ease of demonstrating the apparent successfulness of a rehabilitation program--even when the fundamental research requirement that data be collected and analyzed by independent, disinterested researchers (insofar as any efforts that we undertake to evaluate and publicize the appropriateness, successfulness, and downright brilliance of our own clinical work are rarely disinterested) is met--is due in part to the low base rate phenomenon. Cases of therapist-patient sex abuse have demonstrated that it is possible for perpetrators to engage in sex with their patients undetected (at least until one of the patients breaks the "secret" and files a complaint) while receiving close and direct case supervision, even when the supervision is conducted by an experienced and skilled psychologist under the mandate and auspices of a licensing board (in one instance reported by Bates & Brodsky, 1989, a malpractice suit was filed against both the perpetrator/therapist and the board-approved supervisor conducting the rehabilitation/monitoring), while working within a prestigious agency, and while maintaining a high public profile. Formal complaints from patients may be thus the only reliable way in which the failure of a rehabilitation effort can be discovered. Surveys of victims suggest that about 5% actually file formal complaints (e.g., Bouhoutsos, 1984; Pope & Bouhoutsos, 1986); the percentage seems to be significantly less than 5% when the number of cases estimated from anonymous surveys of therapists are compared with the number of complaints reported by regulatory agencies, ethics committees, and the civil courts.
What are the implications of these facts for rehabilitation? Assume that a hypothetical Sex Abuse Rehabilitation Institute will be created to work with 10 offenders referred by the state licensing board. After many years of intensive psychotherapy, education, and supervision--which, as noted earlier, have not shown evidence of effectiveness in preventing sexual abuse of patients--as well as careful use of other methods, the Institute honestly believes that these 10 psychologists have been fully rehabilitated and are ready to resume clinical practice, despite the relatively high tendency toward recidivism. [The APA Insurance Trust (1990) noted that "the recidivism rate for sexual misconduct is substantial (p. 3). The rate may be at least 80% (California Department of Consumer Affairs, 1990; Holroyd & Brodsky, 1977; Pope, 1989b; Sonne & Pope, in press).] Assume that the Institute's interventions are completely ineffective and that every one of these 10 perpetrators will offend again (each with a new patient) once the licensing board allows each to resume practice. Even if the Institute and licensing board track the offenders for the next 20 years, what are the chances that they will discover that even one of the 10 therapists continued to abuse? According to the binomial probabilities, there is a 59.9% likelihood that none of the 10 subsequently abused patients will ever file a complaint. Thus the Institute and licensing board might in good faith publicize glowing findings that all 10 were rehabilitated and that patients and the public were adequately protected when in fact all 10 perpetrators continued to abuse.
At present, the diverse attempts to rehabilitate therapists who perpetrate sexual abuse have not demonstrated success in replicated research studies (even with the misleading "aid" of the low base rate phenomenon). Moreover, executive directors for the California licensing boards for psychologists, social workers, and marriage and family counselors have reviewed rehabilitation attempts. Having encountered more offenders than the licensing boards of other states, the California boards have had opportunity to test the widest variety of rehabilitation approaches. The executive directors concluded that in cases involving therapists who became sexually intimate with a patient, "prospects for rehabilitation are minimal and it is doubtful that they should be given the opportunity to ever practice psychotherapy again" (Callanan & O'Connor, 1988, p. 11).
The dilemma of rehabilitation is not limited to the highly questionable feasibility or demonstrated efficacy of rehabilitation. Among the other aspects of the dilemma are two major questions. First, what level of inviolable integrity and trust, if any, does the profession wish to affirm and sustain? A judge might take a bribe to decide a major case, lose the judgeship, subsequently pay the debt to society through a prison term, and undergo extensive rehabilitation; yet the judge would obviously not resume the bench. A teacher running a preschool might sexually abuse the children, subsequently undergo extensive treatment and rehabilitation and satisfy legal requirements (i.e., jail or probation), and seem to present no threat of further abuse; yet the teacher would not subsequently be granted a license to operate a preschool (unless, of course, the teacher was able to conceal this history of child molesting, perhaps by moving to another state and providing false answers during the application process). If people found to have used their positions of trust to accept bribes for rendering certain legal decisions or to victimize students were allowed to resume the positions of trust that they had betrayed, the nature of those positions-what they mean to the society and to those whose lives they influence-would be profoundly changed. Violation of a clearly understood prohibition against such a grave abuse of power and trust precludes further opportunity to hold these special positions in the legal or educational professions, although numerous other opportunities in law or education (e.g., research, writing, and consultation) remain available to the rehabilitated perpetrator.
Psychology must answer the question of whether psychotherapy involves, requires, and deserves the same level of inviolable trust (both from society and from those who are directly affected by the therapist) and integrity as judiciary and teaching roles within the legal and educational professions. The exceptional privacy and intensity of most psychotherapy relationships should not be overlooked when one confronts this question.
Second, to what degree does the profession affirm and ensure the rights to informed consent of patients directly affected by rehabilitation efforts? When new, not-yet-validated rehabilitation methods for perpetrators are being used on an experimental or trial basis by independent clinicians and professional boards, are the patients who are treated by the perpetrators during these initial investigative trials accorded full awareness and written informed consent to their participation, as the Ethical Principles in the Conduct of Research With Human Participants (APA, 1982) clearly seems to require? If the rehabilitation methods have already been independently validated, are the patients made aware of the nature of evidence supporting the validity of the approach and of any doubts, reservations, or qualifications regarding the safety and potential fallibility of the method? [Footnote1]
Our responsibility to scrutinize carefully the methods for ensuring informed consent used by clinicians, researchers, licensing boards, ethics committees, and others involved in rehabilitation efforts is vital: The patients placed at risk for serious harm are predominantly female, and informed consent procedures may be less adequate or completely nonexistent when risks for harm from experimental efforts fall mainly on women and minorities (Gallagher, 1990; R. J. Levine, 1988).
Psychologists must overcome professional resistance to the collection and public disclosure of such data (see the section on Acknowledging the Scope of the Phenomenon). It may also be worth considering whether any victim of rape, sexual abuse from a therapist or of incest who is considering seeking help from a therapist is genuinely aware that the therapist she or he selects may have sexually abused patients and has been returned to practice, after some sort of rehabilitation effort, by licensing boards.
A responsible professional stance is incompatible with neglect of these issues. All of us must maintain an active and knowledgeable awareness of such factors as (a) the consent forms and other components used by those (e.g., individual clinicians, professional licensing and ethics boards) who develop, study, publicize, and use rehabilitation attempts that have not yet been formally validated to ensure adequate informed consent by patients placed at risk by the perpetrators, and (b) the measures used to assess the reliability and validity of untested (i.e., having yet to show demonstrable effectiveness) approaches to rehabilitation, with special attention to how the psychometric properties of those measures and how the low base rate of discovery of abuse are taken into account.
Are Patients Responsible for Therapist-Patient Sexual Abuse?
If the history of other forms of sexual abuse such as incest and rape is a useful guide, it is likely that psychology will need to confront more directly the issue of the degree to which a patient will be viewed as responsible for intimacies with a therapist. The prominent psychiatrist Lauretta Bender, for example, stressed the frequency with which the child engaging in sex with an adult is "the actual seducer rather than the one innocently seduced" (Bender & Blau, 1937, p. 514). Similarly, Henderson (1975) concluded, "The daughters collude in the incestuous liaison and play an active and even initiating role in establishing the pattern" (p. 1536). The focus on the victim as responsible for sexual abuse is also a major theme concerning rape. Amir (1971), for example, observed in his classic study of forcible rape, "Thus, the role played by the victim and its contribution to the perpetration of the offense becomes one of the main interests of the emerging discipline of victimology" (p. 258).
These professional views are reflected vividly in the legal system. In one case, the judge refused to confine a person who had pleaded no contest to sexually assaulting a 16-year-old girl. The judge observed that rape is a "normal" reaction to the girl's "provocative clothing" (i.e., blue jeans, a blouse over a turtleneck sweater, and tennis shoes): "Whether you like it or not, a woman's a sex object and they're the ones who turn the man on, generally" ( "A Woman's a Sex Object, " 1977, p. 2). Another judge refused to convict two adults of raping an 8-year-old girl because she was, in the opinion of the judge, "a willing participant" ( "Judge urged to resign, " 1985, p. A6). Still another judge took a 5-year-old girl's "character" into account in discounting the responsibility of the 24-year-old man who sexually assaulted her; the judge observed that the girl was "an unusually sexually promiscuous young lady. No way do I believe that [the adult] initiated the sexual contact" ("Unbelievable, " 1983, p. F2). A recent study revealed that for jurors, evidence concerning the victim's "moral character" tended to count more in rape cases than did medical evidence or other evidence regarding the injury (Mansnerus, 1989, p. 20).
Psychology must struggle with the question of the degree to which it will endorse and focus on the concept of patients as responsible (e.g., through their clothing, behavior, clinical syndromes such as borderline or hysterical disorder, sexual histories or tendencies, difficulty managing boundaries or limits, etc.) for therapist-patient sexual intimacies. Wright (1985), for example, argued that there is no power imbalance in therapeutic relationships: "The therapist is every bit as much in the power of the consumer, as the consumer is in the power of the therapist. In that sense, the relationship is no different from any other human interaction" (p. 117). He maintained that the vulnerability of the therapist invites abuse by the patient; some "consumers recognize the vulnerability of the provider and are attempting to exploit that vulnerability for economic gain" (p. 114). But in Wright's analysis, which he noted was based on his extensive experience chairing The APA Insurance Trust and on his professional work with both victims and perpetrators, not all of the patient's motivations to engage in sex with a therapist and to file a subsequent complaint are economic. Attempting to provide a more complete answer to his fundamental questions of whether and why "they are unable to set limits for themselves or the provider" (p. 116), Wright asserted "the very strong probability that the real reason 'victim/patient' didn't set a limit for the provider [or file a formal complaint] was the unwillingness of that same 'victim' to give up personal gratification [the consumer enjoyed in the relationship]" (p. 116; bracketed text appears in the original).
Similarly, Serban (1981) focused on the motives and characteristics of the patient; the only suffering that can result from therapist-patient sex and the only reason why a patient might "complain against the previous mutual agreement to engage in sexual interaction that she negotiated with her therapist" is, according to Serban, that the results are "not meeting her self imposed expectations" (p. 81). The female patient's expectations from sex with the therapist are, according to this view, "finding either a sexual and emotional partner or otherwise to make a handsome financial profit by defrauding the therapist's insurance, if not to victimize him as revenge against men" (p. 81); complaints are thus based on the patient's anger at the failure of the therapist, despite the patient's having entered into a sexual relationship, to "satisfy her dreams of either marrying her or compensating her financially" (p. 82).
Expert witnesses and defense attorneys have frequently maintained this focus on the motives, acts, or characteristics of the patient. One attorney with substantial experience in trying such cases (and who had similar experience defending people accused of rape) stressed that in therapist-patient sex cases, the primary "defense includes trying to prove that the victims are promiscuous, trying to prove the clients were asking for it" (Terwilliger, 1989a, p. D1). Thus a detailed exploration of the patient's entire sexual history, orientation, current and previous sexual partners (by name so that they can be deposed by the defense attorney in order to obtain baseline data about the patient's previous sexual relationships and sexual functioning), desires, fantasies, and characteristics may become a focus of the trial and perhaps a matter of public record. A patient described the questions that she was directed by the defense attorney to answer under oath:
Could I mentally control vaginal lubrication? At what angle were my legs spread? Did I have orgasms?... Have you ever had occasion to swap sexual partners with anybody?... Have you ever had sex in front of anybody else?... And when you engaged in sex, did you just have intercourse with these people or would you have oral sex with them, too? ( Bates & Brodsky, 1989, p. 66)
The attorney also asserted that in order to present the psychologist's case properly, he would require "a photograph of [the patient] to circulate at local bars... in order to gather information about [the patient's] social life" (Bates & Brodsky, 1989, pp. 105-106). One prominent defense attorney publicly called attention to the patient's race, presumably as a relevant factor in assessing the degree to which the patient should assume responsibility for failing to set limits for herself or the provider: "She was, you know, free, white and 21" (Terwilliger, 1989b, p. F1).
It is interesting to contrast the detailed interest that legal and mental health professionals have taken in eliciting information from patients who have been victimized or may be at risk for victimization regarding their "promiscuity, " sexual history, "predisposing" clinical conditions, difficulties setting limits, and so forth, with the less-than-vigorous efforts to obtain such information from professionals who have engaged in sexual intimacies with their patients. The chair of the Ethics Committee of the American Psychiatric Association explained why the association did not support the national anonymous survey of its members (i.e., Gartrell et al., 1986, 1987, 1989): The organization does not believe in asking its members for "sensitive information about themselves" (Bass, 1989, p. 28).
In struggling with the question of whether to place part or all of the responsibility for therapist-patient sexual intimacies on the patient-an effort that some might term "blaming the victim" (Ryan, 1971)-it would be useful to keep in mind the data that have been accumulated to date. As Bates and Brodsky (1989) summarized, "The best single predictor of exploitation in therapy is a therapist who has exploited another patient in the past" (p. 141). It might also be useful to consider Israel's approach to the problem of rape, which was reaching epidemic proportions in Tel Aviv. The Prime Minister's cabinet (mostly male) spent considerable time discussing ways in which women were putting themselves at risk (e.g., in venturing out alone, in staying out after dark). The cabinet concluded that, in light of women's seeming contribution to the epidemic, a legally enforced curfew for women in the city should be enacted. The Prime Minister, Golda Meier, changed the focus of the deliberations by remarking, "Why not a curfew for the men? They are the ones doing the raping" (Unger, 1979, p. 427).
Confronting the reality of the sexual abuse of patients, both before and after termination, is proving to be a difficult and stressful task for psychology, as it is for all mental health professions. Part of the problem may be our discomfort with even acknowledging sexual attraction to our patients (Maruani, Pope, & de Verbizier, in press; Pope, Keith-Spiegel, & Tabachnick, 1986). Part may be our difficulty confronting issues of abuse that predominantly affects women and is predominantly perpetrated by men (Frieze, 1986; Gilbert & Scher, 1989; L. E. A. Walker, 1979, 1989). Part may be our difficulty handling sexual issues in our training programs and relationships with our students (Glaser & Thorpe, 1986; Pope, 1989a; Pope, Levenson, & Schover, 1979; Robinson & Reid, 1985). Part may be our failure to become aware of and learn from examinations of sex abuse by others in relationships of trust, such as the clergy (Hulme, 1989 ; Rassieur, 1976), sex therapists (Redlich, 1977; Schover, 1989), and nonprofessional hospital staff (Collins, 1989 ; Kirstein, 1978). Part may be our reaction to the fact that we want to preserve both our private and the public image of the profession as one that helps vulnerable and hurting people. We may find it all but impossible to acknowledge fully and to respond adequately when it is (members of) our own profession abusing the vulnerable person. In this sense, we may find ourselves in the position of an enabling member of an incestuous family: We may act in ways that keep the "family secret" (sometimes termed the professional "conspiracy of silence"; see Gallagher, 1990; Macklin, 1987), that obscure the responsibilities of the abusive professional and of his or her colleagues (i.e., us), that enable the perpetrator to continue the abuse (perhaps after an unvalidated rehabilitation program), and that excuse, justify, distort, deny, or discount the reality of what is happening.
Such reasons may help explain our failure-as individuals and as a profession-to address this phenomenon fully and effectively, but they are not an adequate excuse. When our profession ceases to tacitly condone, passively tolerate, or actively collude with the sexual abuse of patients-when, for instance, those who perpetrate such abuse are not allowed to continue or resume working with patients but will need to engage in some other form of psychological practice (e.g., research, consultation, writing, policy, administration)-the trust that both patients and the public are able to bestow on the profession may be of a far more realistic character and may be more genuinely deserved. Awareness of the dilemmas, challenges, and pitfalls characterizing responses to other forms of sex abuse may encourage a more careful and informed response to the sexual abuse of therapy patients and may play a key role in psychology's scientific, professional, and ethical development.
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Footnote #1: Readers may wish to
obtain and review the consent forms used by individual clinicians, clinics,
licensing boards, ethics committees, and others who are developing,
implementing, supervising, or authorizing either experimental or fully
tested rehabilitation approaches for offending therapists to ensure
that the ethical and legal rights of the (mostly female) patients who
are affected are not violated. Civil suits-some of which lead to large
verdicts for plaintiffs-against offending therapists seemed to play
an important role in bringing widespread attention to the importance
of protecting patients from abuse (Pope & Bouhoutsos, 1986); it
would be regrettable if civil suits against those involved in implementing
rehabilitation programs were similarly necessary to highlight the necessity
of ensuring that fully informed consent has been obtained from patients
treated by the offending therapists in various stages of rehabilitation.
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