Sexual boundary violations: victims, perpetrators and risk reduction

Erotic Feelings Towards Patients in the Psychotherapy Session: Investigating Their Relationship With the Characteristics of the Therapist, the Patient, and the Treatment

Experiencing erotic feelings towards a patient is a fairly common occurrence, not pathological per se, during phases of psychotherapy. This study aims to analyze associations between, on the one hand, the presence in therapists of romantic attraction (RA), sexual attraction (SA), or flirting behavior (FB) toward patients and, on the other hand, a series of characteristics of therapist, patient, and treatment. Between April and June 2022, 547 psychotherapists completed an online survey investigating their affective and behavioral responses toward their most recently treated patient. Compared to female therapists, males showed significantly higher prevalence of SA alone (p < .001) or in combination with RA (p < .01), FB (p < .01), or both (p < .05). Multivariate adjusted regression models showed that RA was associated with patient age ≤40 years (OR:39.49 for age 18-29; OR:28.44 for age 30-39), male sex (OR:10.40), and diagnosis of mood disorder (OR:14.08). Furthermore, RA was associated with intense countertransference feelings of tenderness towards the patient (OR:79.77) and hostility towards significant figures in their life (OR: 77.93). SA was associated with the therapist's male sex/gender (OR: 16.14), psychoanalytic orientation (OR:13.34), post-license experience ≤20 years (OR:6.12 for 1-9 years; OR:6.08 for 10-19 years). Lastly, FB was associated with the therapist's male sex/gender (OR:16.94).

A Proposed Approach to Allegations of Sexual Boundary Violation in Health Care

BACKGROUND

Sexual boundary violations in the health care setting cause harm for victims, threaten an organization's culture, and create extraordinary organizational risk. The inherent complexities of health care organizations present unique challenges for the initial triage and response to reports of alleged violations.

METHODS

A group of experts with experience in law, leadership, human resources, medicine, and health care operations identified processes for organizations to triage and implement an early response to allegations of sexual boundary violations. The group reviewed a series of 100 reports of alleged violations described by patients and coworkers from a 200-hospital professional accountability collaborative to identify the elements of an ideal initial triage and management approach.

RESULTS

The group identified three domains to guide early triage and response to reports of boundary violations: (1) severity and acuity of the alleged violation; (2) roles and relationship(s) of the complainant, respondent, and other affected individuals; and (3) contextual information such as prior activity or other mitigating factors. The group identified leadership engagement; coordinated responses; clear articulation of values, policies, and procedures; aligned data reporting; thoughtful reviews; and securing appropriate resources as essential elements of an organization's response.

CONCLUSION

A structured systematic approach to classify and respond to allegations of sexual boundary violation is described. The initial response should be guided by assessment of the severity and timing of the reported behavior, followed by assessment of roles and responsibilities with involvement of all relevant stakeholders. Contextual issues and special circumstances of relevance should be identified and incorporated into the response. Systems to identify, store, and retrieve behavior of concern should be improved and integrated.

Combining rules and dialogue: exploring stakeholder perspectives on preventing sexual boundary violations in mental health and disability care organizations

Background

Sexual boundary violations (SBV) in healthcare are harmful and exploitative sexual transgressions in the professional–client relationship. Persons with mental health issues or intellectual disabilities, especially those living in residential settings, are especially vulnerable to SBV because they often receive long-term intimate care. Promoting good sexual health and preventing SBV in these care contexts is a moral and practical challenge for healthcare organizations.

Methods

We carried out a qualitative interview study with 16 Dutch policy advisors, regulators, healthcare professionals and other relevant experts to explore their perspectives on preventing SBV in mental health and disability care organizations. We used inductive thematic analysis to interpret our data.

Results

We found three main themes on how healthcare organizations can prevent SBV in mental health and disability care: (1) setting rules and regulations, (2) engaging in dialogue about sexuality, and (3) addressing systemic and organizational dimensions.

Conclusion

Our findings suggest that preventing SBV in mental health and disability care organizations necessitates setting suitable rules and regulations and facilitating dialogue about positive aspects of sexuality and intimacy, as well as about boundaries, and inappropriate behaviors or feelings. Combining both further requires organizational policies and practices that promote transparency and reflection, and focus on creating a safe environment. Our findings will help prevent SBV and promote sexual health in mental health and disability care organizations.

Predicting boundary violation propensity among mental health professionals

Despite its clear importance, there have been very few empirical investigations of boundary violation propensity among mental health professionals. The present study explored the relationships between self-reported propensity for boundary violations and predictors theorized to increase their likelihood. Australian mental health professionals (N = 275) completed an online questionnaire battery including demographics, the Sexual Boundary Violation Index, Boundaries In Practice Scale, Boundary Violations Propensity Questionnaire, Marlow-Crowne Social Desirability Scale, Circumplex of Interpersonal Problems, Brief Inventory of Pathological Narcissism, Barratt Impulsiveness Scale Brief Version, Satisfaction with Life Scale, Brief Experiential Avoidance Questionnaire, Adverse Childhood Experiences Questionnaire, and the Interpersonal Reactivity Index. Regression analysis was used to identify unique predictors. Boundary violation propensity was associated with nurturant interpersonal styles in females and dominant interpersonal styles in males. In regression analysis, unique predictors for male boundary violation propensity were grandiose narcissism, vulnerable narcissism, self-centred interpersonal traits, and low levels of empathic concern. For females, unique predictors were impulsivity, childhood adversity, self-sacrificing interpersonal traits, and vulnerable narcissism. In addition to informing theory about those at risk of perpetrating boundary violations, the identified predictors can inform those involved in selection for training programmes and staff appointments and serve as markers for providing closer supervision.

Complaint risk among mental health practitioners compared with physical health practitioners: a retrospective cohort study of complaints to health regulators in Australia

OBJECTIVES

To understand complaint risk among mental health practitioners compared with physical health practitioners.

DESIGN

Retrospective cohort study, using incidence rate ratios (IRRs) to analyse complaint risk and a multivariate regression model to identify predictors of complaints.

SETTING

National study using complaints data from health regulators in Australia.

PARTICIPANTS

All psychiatrists and psychologists ('mental health practitioners') and all physicians, optometrists, physiotherapists, osteopaths and chiropractors ('physical health practitioners') registered to practice in Australia between 2011 and 2016.

OUTCOME MEASURES

Incidence rates, source and nature of complaints to regulators.

RESULTS

In total, 7903 complaints were lodged with regulators over the 6-year period. Most complaints were lodged by patients and their families. Mental health practitioners had a complaint rate that was more than twice that of physical health practitioners (complaints per 1000 practice years: psychiatrists 119.1 vs physicians 48.0, p<0.001; psychologists 21.9 vs other allied health 7.5, p<0.001). Their risk of complaints was especially high in relation to reports, records, confidentiality, interpersonal behaviour, sexual boundary breaches and the mental health of the practitioner. Among mental health practitioners, male practitioners (psychiatrists IRR: 1.61, 95% CI 1.39 to 1.85; psychologists IRR: 1.85, 95% CI 1.65 to 2.07) and older practitioners (≥65 years compared with 36-45 years: psychiatrists IRR 2.37, 95% CI 1.95 to 2.89; psychologists IRR 1.78, 95% CI 1.47 to 2.14) were at increased risk of complaints.

CONCLUSIONS

Mental health practitioners were more likely to be the subject of complaints than physical health practitioners. Areas of increased risk are related to professional ethics, communication skills and the health of mental health practitioners themselves. Further research could usefully explore whether addressing these risk factors through training, professional development and practitioner health initiatives may reduce the risk of complaints about mental health practitioners.

Explanatory paradigms for professional boundary violations

In this commentary, I draw on Hook & Devereux to explore the role of insecure attachment in boundary-violating doctors. I also explore the potential contribution of personality dysfunction in that small proportion of doctors who breach professional boundaries.

DECLARATION OF INTEREST

G. A. worked with Dr Hook at St George's Hospital, London, and has also worked at the Clinic for Boundaries Studies, where he has worked.

Boundary violations in therapy: the patient's experience of harm

Harm in talking therapies, and in healthcare professionals’ relationships with patients generally, has received little attention in comparison with harm by medication and other treatments. There has been little research into causes, types and effects. Professionals behave as if it does not happen and tend to react defensively to complaints. We believe that it is essential for professionals to understand the potential for harm and evaluate their actions in order to make them safer. This article defines harm in the therapeutic context, discusses its prevalence and then focuses on adverse idealising transference: the adverse effects that may arise when a patient transfers idealising feelings onto the professional.

LEARNING OBJECTIVES

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DECLARATION OF INTEREST

None.