A Brief History of Sexual Boundary Violations1

In the film Lovesick, a 1983 romantic comedy made shortly past the end of the so-called “Golden Age” of psychoanalysis in the United States, Dudley Moore portrays a typical Manhattan psychoanalyst, Saul Benjamin, who falls in love with a patient, Chloe Allen, a young, talented, magically appealing but not overtly seductive playwright portrayed by Elizabeth McGovern at an early stage of her career. They become involved in a romantic and sexual relationship. Despite its relative obscurity, the film is notable for its spot on portrayal of New York psychoanalysts of that era, including the appearance of their offices, their decor, dress and pretentiousness, the officious behavior of their “committees” and their flirtations with the arts. The ghost of Sigmund Freud, played by Alec Guinness, appears now and then to offer wise and sarcastic comments about Dr. Benjamin's behavior. In his February 18, 1983 review of Lovesick in the New York Times, Vincent Canby wrote that the film “may be the most indigenously New York comedy since Woody Allen's Manhattan.”

Lovesick is at its best in portraying and parodying a patient's infatuation with her analyst and the latter's reciprocal if guilty passion. “I had the weirdest dream last night,” Chloe confesses to Dr. Benjamin, “It's kind of intimate—a sex dream.” The analyst can hardly restrain his curiosity, and when she hesitates to elaborate on the details of the dream, he invites her to lie on his couch. “I was in a strange new place,” she continues, “with a strange man who was very wise and gentle and kind.” In the dream, the stranger is making love to her, giving her great pleasure. “His name was Herzog,” Chloe recalls, adding, “I don't know anyone of that name.” Dr. Benjamin asks her to free associate on the name, and she suddenly remembers a novel called Herzog written by Bellow, whose first

name she has forgotten. “The author's first name is Saul, Saul Bellow,” Dr. Saul Benjamin replies with a straight face, to which she exclaims, “Oh boy!”

As entertaining to some as Lovesick might have been, however, the story is illustrative, if not typical, of a serious problem that has haunted the psychotherapy professions from the earliest era of Freud himself down to the present day. Sexual involvement between therapists and patients is sufficiently common that modern day psychotherapists are no longer surprised by reports of colleagues who have taken the misstep of crossing the line in what is primly called in the profession a “sexual boundary violation,” but what has been more recently called in the law and by regulatory authorities “sexual misconduct,” “professional misconduct,” “assault,” “malpractice,” “unethical behavior,” or even “rape.” Because of Lovesick's depiction of a romantic relationship with a happy ending, the film was criticized by many mental health professionals. “It can be argued,” Krin Gabbard and Glen O. Gabbard observe in Psychiatry and the Cinema, “that Lovesick is the most insidious depiction of a psychiatrist acting on erotic countertransference feelings that has ever appeared on film” (149). In Hollywood on the Couch, Stephen Farber and Marc Green characterize Lovesick as “one of the most incendiary of all cinematic treatments of psychiatry” (197).

Space does not permit us to review the extensive studies that have illuminated sex in the patient-therapist relationship, but a few statistics suggest the dimensions of the problem. Citing a dozen different studies from 1973 to 2001, Andrea Celenza states in Sexual Boundary Violations that the number of therapists who admitted to sexual contact with one or more patients in the United States ranged from 7–12% (6). Most of these studies involve psychotherapists who responded to questionnaires asking whether they had erotic contact with patients. Several self-reporting surveys reveal—according to Linda Jorgenson, Steven B. Bisbing, and Pamela K. Sutherland in a 1992 study—that the incidence of therapists who engaged in some form of erotic contact with one or more patients was nearly 14% (596). According to Celenza, “male practitioners account for over 80% of the incidences [i.e., perpetrators]” (7). One might wonder if sexual boundary violations are unique to psychotherapists, since instances of such misconduct have been reported in a number of professions and medical specialties. However, a 1998 review

of state disciplinary actions makes clear that of all the medical specialties, psychiatrists had been involved in such misconduct in numbers grossly out of proportion to their representation among the specialties, comprising about 28% of such cases from a pool of medical practitioners in which psychiatrists were 6.3% of the overall medical profession (Dehlendorf and Wolfe). This is a 4.4 fold overrepresentation and is statistically a highly significant finding. At the time of the 1998 review, there was some evidence that the rate of such misconduct among psychiatrists was slowly decreasing, partly because many psychiatrists were abandoning psychotherapy as a treatment modality and turning to psychopharmaceuticals and other somatic treatments, and partly because a gradually increasing number of psychiatrists are women.

The extent of this problem comes to light in the compilations of documented cases assembled by some seemingly or even admittedly “antipsychiatry” websites that devote much energy to—and seem to take glee in—assembling their depressing lists. Some of these websites serve a more positive role, however, in allowing victims to locate help and support from experts in the profession, feel validated, find therapists, receive educational materials and learn about their legal rights. The website “Psychiatric & Mental Health Rape Reporter” has assembled 330 documented examples since 2009 (). Furthermore, growing public awareness of this issue is shown in N. M. Gharaibeh's 2005 study of American films about psychiatrists. Of 106 such films, a highly disproportionate 45% showed boundary violations of one sort or another; approximately half of these, a total of 26, were sexual violations.

Transference

To understand the phenomenon of “lovesickness” in psychotherapy and how it might lead to sexual boundary violations, we must first understand the related phenomena of transference, transference-love and countertransference. Freud's most complete discussion of transference appears in An Autobiographical Study , where he vividly captures its fraught complexity and significance:

In every analytic treatment there arises, without the physician's agency, an intense emotional relationship between the patient and the analyst which is not to be accounted for by the actual situation.

Page 13

It can be of a positive or of a negative character and can vary between the extremes of a passionate, completely sensual love and the unbridled expression of an embittered defiance and hatred. This transference—to give it its short name—soon replaces in the patient's mind the desire to be cured, and, so long as it is affectionate and moderate, becomes the agent of the physician's influence and neither more nor less than the mainspring of the joint work of analysis. Later on, when it has become passionate or has been converted into hostility, it becomes the principal tool of the resistance. It may then happen that it will paralyse the patient's powers of associating and endanger the success of the treatment. Yet it would be senseless to try to evade it; for an analysis without transference is an impossibility. (SE, vol. 20, 42)

One of Freud's greatest discoveries, transference involves a person's largely unconscious projective tendencies, a phenomenon intensified through psychoanalysis. The patient sees in the analyst, Freud remarks in An Outline of Psycho-Analysis , “the return, the reincarnation, of some important figure out of his childhood or past, and consequently transfers on to him feelings and reactions which undoubtedly applied to this prototype. This fact of transference soon proves to be a factor of undreamt-of importance, on the one hand an instrument of irreplaceable value and on the other hand a source of serious dangers” (SE, vol. 23, 174–175).

Transference-Love

One of the most serious dangers of transference, as Freud reveals in

“Observations on Transference-Love” , occurs when patients fall in love with their analysts. “This situation has its distressing and comical aspects, as well as its serious ones. It is also determined by so many and such complicated factors, it is so unavoidable and so difficult to clear up, that a discussion of it to meet a vital need of analytic technique has long been overdue. But since we who laugh at other people's failings are not always free from them ourselves, we have not so far been precisely in a hurry to fulfil this task” (SE, vol. 12, 159).

Freud was the first to acknowledge the many ambiguities of transference-love. After noting in “Observations on Transference-Love” that it is created by the analytic situation and that the “outbreak of a passionate demand for love is largely the work of resistance” (162), he concedes that transference–love “consists of new editions of old traits and that it repeats infantile reactions. But this is the essential character of every state of being in love” (168). Nevertheless, Freud concludes, an element of unreality surrounds transference-love that distinguishes it from “normal” love.

In one of his first letters to Jung, written in December 6, 1906 at the beginning of their seven-year friendship, Freud emphasized the importance of transference in the therapeutic process. “Essentially, one might say, the cure is effected by love. And actually transference provides the most cogent, indeed, the only unassailable proof that neuroses are determined by the individual's love life” (McGuire, 12–13). This passage has been widely quoted and sometimes misleadingly translated as “Psychoanalysis is in essence a cure through love.” There is no ambiguity, however, over the meaning of Freud's words: he was referring to the patient's transference-love, not the analyst's countertransference.

What should analysts do when patients fall in love with them? It seems to a “layman,” Freud points out in “Observations on Transference-Love,” that there are only two options. “One, which happens comparatively rarely, is that all the circumstances allow of a permanent legal union between them; the other, which is more frequent, is that the doctor and the patient part and give up the work they have begun which was to have led to her recovery, as though it had been interrupted by some elemental phenomenon.” There is, he concedes, a third choice, for analyst and

therapist to enter into an illicit and temporary union. This is impossible, Freud emphatically asserts, because of “conventional morality and professional standards” (160).

How, then, should analysts respond to transference-love? To begin with, the phenomenon “signifies a valuable piece of enlightenment and a useful warning against any tendency to a counter-transference which may be present in his own mind” (160). Freud was reluctant to write about countertransference, the analyst's projective tendencies, because he feared opponents of psychoanalysis would use the concept to call attention to the analyst's subjectivity. He first referred to countertransference in “The Future Prospects of Psycho-Analytic Therapy” , where he makes the noteworthy statement that “no psycho-analyst goes further than his own complexes and internal resistances permit” (SE, vol. 11, 145). Psychoanalytic organizations were so reluctant to call attention to countertransference that it was not until 1984 that the American Psychoanalytic Association was willing to discuss this troubling concept during one of its annual meetings.

Countertransference remains one of the most vexing issues in psychoanalytic training. Analysts must undergo a long training analysis to become aware of their own projective tendencies, the inclination to project onto a patient the feelings and desires they have toward the key people in their own lives. Analysts must recognize—Freud adds with wry, self-deprecating humor—that the “patient's falling in love is induced by the analytic situation and is not to be attributed to the charms of his own person; so that he has no grounds whatever for being proud of such a ‘conquest,’ as it would be called outside analysis” (160–161).

Transference-love is one of the most bedeviling clinical phenomena, and it is “just as disastrous for the analysis if the patient's craving for love is gratified as if it is suppressed.” The situation is perilous because analysts have no model in life to help them. They must steer a course between the Scylla of gratification and the Charybdis of suppression of their patients' transference-love. “He must keep firm hold of the transference-love, but treat it as something unreal, as a situation which has to be gone through in the treatment and traced back to its unconscious origins and which must assist in bringing all that is most deeply hidden in the patient's erotic life into her consciousness and therefore under her control” (166).

Freud never underestimated the potential danger of transference-love. “The psycho-analyst knows that he is working with highly explosive forces and that he needs to proceed with as much caution and conscientiousness as a chemist” (170).

Freud's technical papers on the dynamics of transference emphasize the ease with which positive and negative transference dissolve into each other and the extent to which both may represent resistance to cure. As James Strachey, the general editor of the Standard Edition, points out, the first time Freud mentions the word ambivalence, coined by the Swiss psychiatrist Eugen Bleuler, is in “The Dynamics of Transference” (SE, vol. 12, 106, n.1).

Freud concludes “Observations on Transference-Love” with one of the most prescient paragraphs found anywhere in his writings. “The analytic psychotherapist thus has a threefold battle to wage in his own mind against the forces which seek to drag him down from the analytic level; outside the analysis, against opponents who dispute the importance he attaches to the sexual instinctual forces and hinder him from making use of them in his scientific technique; and inside the analysis, against his patients, who at first behave like opponents but later on reveal the overvaluation of sexual life which dominates them, and who try to make him captive to their socially untamed passion” (170).

Transference is one of Freud's greatest discoveries, but it is also enveloped with great ambiguities, as Thomas Szasz observed in 1963:

Transference is the pivot upon which the entire structure of psycho-analytic treatment rests. It is an inspired and indispensable concept; yet it also harbours the seeds, not only of its own destruction, but of the destruction of psycho-analysis itself. Why? Because it tends to place the person of the analyst beyond the reality testing of patients, colleagues, and self. This hazard must be frankly recognized. Neither professionalization, nor the “raising of standards,” nor coerced training analyses can protect us from this danger. Only the integrity of the analyst and of the analytic situation can safeguard from extinction the unique dialogue between analysand and analyst. (443)

Early Sexual Involvements Between Analysts and Patients

From the earliest days of psychoanalysis, sexual involvements between psychoanalysts and their patients, either during the analysis or after the treatment ended, were reported. As Glen O. Gabbard and Eva P. Lester point out, Carl Jung became involved in “a tempestuous love affair” with a former analysand (his first analytic patient), Sabina Spielrein, in 1906. “The relationship between Jung and Spielrein is a cogent illustration of why so many “post-termination” romantic relationships present the same difficulties as those that are concurrent with analysis. Although the treatment had officially ended, the transference and countertransference dimensions of the relationship continued with a life of their own outside the formal confines of treatment” (72).

The Freud-Jung correspondence over the Spielrein “affair” doesn't prove conclusively that Jung had a sexual relationship with his former patient—he remains evasive over what actually happened between them—but it reveals his ambiguous guilt, a “piece of knavery” that he felt he had to “confess” to Freud “as my father” (236). The correspondence also shows the male analysts' anxiety over “seductive” women. “She has kicked up a vile scandal solely because I denied myself the pleasure of giving her a child,” Jung wrote to Freud on March 7, 1909. Claiming that he has always “acted the gentleman towards her,” Jung nevertheless admits that he doesn't “feel clean,” adding, “you know how it is—the devil can use even the best of things for the fabrication of filth.” Jung learned a painful lesson: “until now I had a totally inadequate idea of my polygamous components despite my self-analysis” (McGuire, 207).

Freud, to whom Spielrein had earlier written a letter sharing some details about her relationship with Jung, sent off a reassuring note to Jung two days later, implying that her accusations were probably without merit. “To be slandered and scorched by the love with which we operate such are the perils of our trade, which we are certainly not going to abandon on their account” (210). Jung followed with a letter written two months later, declaring he had to end his friendship with Spielrein because she was “systematically planning my seduction, which I considered inopportune. Now she is seeking revenge” (228). Jung then discussed the rumor he believed she was spreading about his decision to divorce his wife to marry a student, a rumor, he later ruefully admitted, that did

not originate with her. Three days later Freud wrote a commiseration letter acknowledging that he himself had come “very close” a “number of times” to being in Jung's situation and had had ”a narrow escape,” the last three words in English. Freud adds, in a comment that reflects the convention of blaming the female victim, symptomatic of the masculinist bias of the age, “The way these women manage to charm us with every conceivable psychic perfection until they have attained their purpose is one of nature's greatest spectacles” (230–231).

Gabbard and Lester observe that the affair nearly destroyed Jung's career and brought Spielrein to the edge of despair. Her reaction to Jung's efforts to end the relationship reveals what has been called “cessation trauma” (72), a common reaction to the end of therapy as a result of a sexual boundary violation. As Aldo Carotenuto, the editor of Spielrein's published diaries, remarks, “what we are witnessing is a sick young girl's struggle against Jung and Freud, and it is gratifying to acknowledge that it was the girl who, with shrewdness and perseverance, would win the battle, since both Freud and Jung later claimed her as a pupil!” (175).

Sabina Spielrein later became an analyst and made an important contribution to the early history of psychoanalysis. She was murdered (along with her two daughters) by the Nazis in the Soviet Union in 1942 at the age of 56. In an article published in the Journal of the American Psychoanalytic Association in 2015, Adrienne Harris raises a provocative question. “Do Spielrein's work and reputation continue to be filtered through the anxieties about her relationship with Jung, the hovering suspicions around boundary violations that so often impugn the reputation of the victim?” (732). By showing the significance of Spielrein's many noteworthy publications, Harris succeeds in “turning a ghost into an ancestor” (733).

Otto Rank, one of Freud's closest colleagues before their falling out in 1926, had a sexual affair with his patient Anaïs Nin in the early 1930s. Nin later became an analyst (as well as a celebrated diarist) to whom Rank sent patients. In her 1995 biography, Deirdre Bair quotes a letter that Nin wrote to another paramour, Henry Miller, in which she described her relationship with Rank as “sometimes friends, other times lovers, and fellow professionals in still others” (188). Nin implied in one of her confessional diaries that her father, a notorious Don Juan and

pedophile, sexually abused her when she was nine years old. He resexualized their relationship when they met again after an absence of 20 years, an experience that may have influenced her symbolic incest with Rank. E. James Lieberman remarks in his 1985 biography of Rank that as a sign of his esteem for her, Rank wrote two prefaces, one for her early Diary, the other for her House of Incest, which he encouraged her to complete (348). Both Rank and Nin authored books about incest, and their bond with each other recalls Hamlet's sullenly bitter opening words “a little more than kin, and less than kind” to describe his paradoxical relationship with Claudius.

Another prominent psychoanalyst involved in a sexual scandal was Ernest Jones, perhaps Sigmund Freud's most trusted “lieutenant.” Jones eventually became President of the International Psychoanalytical Association and the author of a famous three-volume biography of Freud. Prior to his becoming one of the earliest practitioners of psychoanalysis in London, Jones, a physician, was charged in 1906 with two counts of sexually assaulting two young “mentally defective girls” at a special school in London and was jailed overnight as a result of those charges. Jones was later found innocent, but Philip Kuhn's 2002 investigation of the evidence raises new questions about his culpability. In 1903, Jones had been forced to resign another hospital post because of a similar accusation, and after the 1906 events, he concluded that his career in London was finished and moved to Canada.

In both London and in Canada, Jones lived for about seven years as the common-law spouse of his former patient Loe Kann, a fact that he casually disclosed to Freud in a letter dated June 28, 1910 (Paskauskas, 62–64). Kann was a wealthy heiress and a morphine addict. Jones and Kann claimed to have been legally married, but a scandal ensued when the truth came out during their period of residence in the hyper-Victorian Canada of that era. While in Canada, Jones was again accused of sexual misconduct, as Brenda Maddox observes (97), and eventually he returned to Europe where he entered analysis with Sandor Ferenczi at Freud's suggestion, while at the same time Freud undertook an analysis of Kann. Later, during the course of that analysis with Freud, about which he regularly corresponded with Jones, Kann fell in love with the son of another of Freud's patients, whom she eventually married and who also happened to be named “Jones.” Ernest Jones, possibly with

some bitterness, referred to his successor as “Jones II” (Maddox, 112).

A number of psychoanalytic scholars have pointed out—most recently, Andrea Celenza—that Freud wrote his papers on technique while he was corresponding with and implicitly criticizing Jones for his seductive behavior with patients. “There is an implication that Freud's development of abstinence, neutrality, and anonymity, as the hallmark components of a proper analytic stance, derived from his concern about Jones and the boundary transgressions of other analysts during this time” (193).

The legendary psychoanalyst Frieda Fromm-Reichmann at age 36 began an affair with her ten-year-younger patient, Erich Fromm, one year after her father's death and eight months after the marriage of her younger sister. At the time, according to her biographer, Gail A. Hornstein, she “was dangerously close to passing marriageable age and becoming a permanent embarrassment to her family” (58). Later Frieda said to friends, “I began to analyze him and then we fell in love. We stopped the analysis. That much sense we had!” (Hornstein, 60). Both had had Orthodox Jewish upbringings. Frieda, a physician, opened a treatment facility based on Orthodox Jewish principles for people with mental disorders, and she and Fromm worked there together. Unable to free themselves through psychoanalysis from the strictures of their religious upbringings, they finally decided to take direct action. As Hornstein relates it, “One Passover afternoon in 1928, Frieda and Erich went out alone leaving behind a house filled with Jews fervently enacting the ancient practices forbidding the consumption of leavened foods.” They walked to a park, in a neighborhood where they wouldn't be recognized, sat down on a bench, and then “with great ceremony” unwrapped and slowly ate a loaf of bread they had secretly purchased. “Neither said a word. For all their sophistication, at some primitive level, they both expected to be struck by lightning or otherwise punished by God at that moment” (66). To their astonishment, nothing happened.

It's not entirely clear what this act of rebellion referred to, since Frieda Fromm-Reichmann and Erich Fromm had married two years earlier, on May 14, 1926. They separated in 1930, around the time Erich began an affair with Karen Horney, one of his teachers at the Berlin Institute. When Frieda and Erich emigrated to the United States, they came separately, but they continued to be friends thereafter. Both became well

known personalities in the psychiatric and U.S. cultural world following their arrival. Frieda and Erich waited until 1942 before they formally divorced. Commenting on the marriage between Frieda, the analyst, and her patient, Hornstein points out, “Of course, things were a lot looser in the analytic world of the 1920s, where people were constantly having affairs with their patients or marrying them” (401).

Karen Horney's affairs with her supervisees and analysands at the psychoanalytic institutes with which she was associated were also well known at the time. According to the biographer Bernard J. Paris, Horney was described by a colleague, Roy Grinker, as a “very seductive woman” who had sexual relationships with younger analysts at the Chicago Psychoanalytic Institute; one of these analysts, Leon Saul, was “traumatized” by the experience (142). There were similar stories about Horney's disruptive behavior at the New York Psychoanalytic Institute, where she had the reputation of emotionally damaging the younger analysts-in-training with whom she slept. Horney's secretary at the New York Psychoanalytic Institute suggested that one of the reasons the sexually aggressive psychoanalyst had affairs with younger men was her need for disciples. Like Hornstein, Paris points out that the rules against analysts having sex with candidates in a training analysis or under their supervision are far stricter nowadays than in the past. Descriptions of these and other notable early examples can be found in Glen O. Gabbard's “The Early History Of Boundary Violations In Psychoanalysis.”

Masud Khan

Of all the best-known psychoanalysts of the second half of the twentieth century, the one whose behavior was probably the most egregious was Masud Khan . He was born in the district of British India that later became Pakistan; his mother was a 17-year-old dancer when she became the fourth wife of his 76-year-old wealthy landowner father. A graduate of the British Psychoanalytic Association, he authored several highly regarded books. Anna Freud greatly admired the charismatic Khan, and his most recent biographer, Linda Hopkins, observes in False Self: The Life of Masud Khan that in 1976 Erik Erikson exclaimed, “The future of analysis belongs to Khan!” (xxii). But that was before Khan's career self-destructed. Hopkins documents how Khan slept with his patients, patients' wives, and daughters of friends

and acquaintances. Hopkins shows how Khan's life spiraled out of control as a result of alcoholism, grandiosity, and mental disease, which she speculates was bipolar disorder.

Can Sexual Relations Be a Form of “Therapy”?

Some of the most appalling examples of sexual boundary violations have taken place under the guise that erotic contact between the psychotherapist and the patient is a form of treatment. The idea of sex (acknowledged as that or not) as a form of treatment has its own history.

In her controversial The Technology of Orgasm: “Hysteria,” the Vibrator, and Women's Sexual Satisfaction , Rachel P. Maines describes the use of “massage” and eventually the 19th century introduction of medical instruments (vibrators) by physicians to treat “hysteria,” a condition that existed for possibly as long as thousands of years. According to Maines, physicians had been treating, with varying degrees of awareness of what they were doing, female hysterical patients by inducing orgasms in such patients through “massage” of the patients' genitals. The sexual nature of this “treatment” was seemingly unacknowledged or denied by both patients and doctors. Instead, this widely used procedure was said to produce an “hysterical paroxysm” (actually an orgasm) leading to temporary resolution of the symptoms. Although the origin of this practice in antiquity is uncertain, Maines' evidence for its having been used in more recent times is quite convincing.

In her book's opening chapter, “The Job Nobody Wanted,” Maines describes the replacement by physicians of manual massage with medical vibrators and the mixed awareness among physicians as to what they were doing. A fictionalized story of the invention of the vibrator, based on Maines' book, was told in the play In the Next Room (or The Vibrator Play), described by Charles Isherwood in his February 18, 2009 review in the New York Times as a “fanciful but compassionate consideration of the treatment, and the mistreatment, of women in the late 19th century.” The invention of the vibrator also appears in the 2008 documentary film Passion & Power, written and directed by Emiko Omori and Wendy Blair Slick, and in the 2011 British film comedy Hysteria, directed by Tanya Wexler. Historians have been largely unaware of this practice in the early history of the psychoanalytic movement.

Yet Sigmund Freud was well aware of the role that therapeutic “massage” was playing in the treatment of hysterics in his day. Commenting on the treatment of “anxiety neurosis,” he writes in his little-read 1895 essay “On the Grounds for Detaching A Particular Syndrome from Neurasthenia Under the Description ‘Anxiety Neurosis’”:

So long as an anxiety neurosis in young married women is not yet established, but only appears in bouts and disappears again spontaneously, it is possible to demonstrate that each such bout of the neurosis is traceable to a coitus which was deficient in satisfaction. Two days after this experience or, in the case of people with little resistance, the day after the attack of anxiety or vertigo regularly appears, bringing in its train other symptoms of the neurosis. All this vanishes once more, provided that marital intercourse is comparatively rare. A chance absence of the husband from home, or a holiday in the mountains, which necessitates a separation of the couple, has a good effect. The gynaecological treatment which is usually resorted to in the first instance is beneficial because, while it lasts, marital intercourse is stopped. Curiously enough the success of local treatment is only transitory: the neurosis sets in again in the mountains, as soon as the husband begins his holiday too; and so on. If, as a physician who understands this aetiology, one arranges, in a case in which the neurosis has not yet been established, for coitus interruptus to be replaced by normal intercourse, one obtains a therapeutic [emphasis in original] proof of the assertion I have made. The anxiety is removed, and unless there is fresh cause for it of the same sort it does not return. (SE, vol. 3, 103–104; emphases added; Fink 38–44)

Treatment of sexual dysfunction using actual sexual encounters became an established practice following the pioneering work of Masters and Johnson in the 1960s. The two world-famous sex researchers described in their book Human Sexual Inadequacy a therapeutic technique involving the employment of “sexual surrogates” whose assigned task was to work with the partnerless patients to resolve their sexual inhibitions or other problems by engaging in sexual relations. The “treatment” by the surrogate was prescribed by the patient's psychotherapist or “sex therapist” who made the referral and typically communicated on a regular basis with the surrogate. Cheryl T. Cohen-Greene became well known for her work as a sexual surrogate; she wrote about her experiences in her

2012 memoir An Intimate Life: Sex, Love, and My Journey as a Surrogate Partner. The film The Sessions depicts her work with a severely disabled client.

Although they popularized the use of sexual surrogates, Masters and Johnson eventually set forward the view in “Principles of the New Sex Therapy” that it was inappropriate for a therapist or surrogate to engage in sex as part of the treatment of a patient's sexual dysfunction. Using unusually strong language, Masters and Johnson went out of their way to condemn such behavior. “We feel that when sexual seduction of patients can be firmly established by due legal process, regardless of whether the seduction was initiated by the patient or the therapist, the therapist should initially be sued for rape rather than for malpractice, i.e., the legal process should be criminal rather than civil” (553). Masters and Johnson asserted that patients who are emotionally dependent on a therapist cannot make an “objective” decision to have sex in therapy. Nor did the two researchers believe that therapists would be willing to appear in court on behalf of colleagues who have had sex with their patients. Contrary to Masters and Johnson's recommendation, most patients who sue their therapists for sexualizing treatment do so in civil rather than in criminal court, mainly because the lack of corroborative proof generally associated with these cases requires only a “preponderance of evidence,” a legal standard lower than that of “beyond a reasonable doubt.”

The researchers' public statements, however, were duplicitous. According to Thomas Maier's account of their work in Masters of Sex, Masters and Johnson continued to employ sexual surrogates in their therapeutic practices but believed they needed to do so in secret after a lawsuit by a husband of a surrogate threatened to destroy their clinic (201). Masters “never wavered” in his belief that surrogates were essential in the treatment of certain disorders (309). In the operation of their clinic, however, they took steps to keep financial dealings with the surrogates off the books (314).

Although nearly all contemporary psychotherapists believe that sexual relations with patients are unhelpful and even dangerous, there were dissenting voices on this subject in past decades. In the midst of the “sexual revolution” during the 1960s and 1970s, at least two psychotherapists

published their views along with anecdotal examples from their own practices that having sex with certain patients was an important contribution to their recovery. One of these therapists, Martin Shepard, we describe in a later chapter; the other, James L. McCartney, we describe below. Even those opposed to any such interaction, based on subsequent survey evidence that 90% of patients who have had sex in therapy have found the experience harmful, would have to admit that for the remaining 10% of patients, the experience might have been benign or even helpful (Bouhoutsos et al.). Most health care experts would say, however, that a procedure with such a dismal risk/benefit ratio should not be considered except in major life threatening illnesses for which there is no alternative.

We will have much to say in a later chapter about Carolyn M. Bates and Annette M. Brodsky's Sex in the Therapy Hour, a book that was a catalyst behind the American Psychological Association's decision to reject sex between a therapist and patient, but for now we'll quote the authors' observation that several studies conducted in the 1970s and 1980s indicate a “persistent minority belief that there may be a positive value to sexual intimacy between patients and therapists” (130). Part of this minority belief may arise over the ambiguities of defining sexual intimacy: “kissing, hugging, affectionate touching, or stroking could easily have more than one meaning for either of the parties involved” (130–131). Bates and Brodsky cite a 1977 study conducted by Brodsky and Holroyd that asked mental health professionals who admitted having sex with patients to explain why they believed sex could help themselves or their patients. “Among the few respondents who reported believing that sexual intimacy could be beneficial, various contradictory circumstances were mentioned: The patient was particularly inexperienced and therefore needy of sex, or, conversely, the patient was very experienced and therefore needy of sex. Some believed sex might be appropriate only if it was related to the patient's problems or, conversely, only if it had nothing to do with the patient's problems. There was no consensus as to situations under which a patient might benefit” (151–152).

Andrea Celenza refers to a 1992 study by Gutheil and Gabbard indicating that slightly more than one-third of the patients who initiated sexual contact in therapy reported that they were “not adversely affected.” Celenza rightly notes, however, that it's unclear if they would feel the

same way over time. She then cites another study indicating that female victims who initially reported experiencing pleasurable feelings during sexualized therapy saw the experience as “hurtful or exploitative in retrospect” (132).

Current Professional Viewpoints and Legal Status

Writing in 1995, Glen O. Gabbard, an expert on the subject, pointed out in “The Early History of Boundary Violations in Psychoanalysis” that the problem of sexual violations is not only widespread but also a continuing abuse that must be faced by every practitioner:

Every psychoanalytic institute and society has seen the ravages of severe boundary violations. It would be tempting for us to attribute these transgressions to a small handful of corrupt colleagues who suffer from severe character pathology and a propensity to act rather than reflect. This point of view allows all of us to projectively disavow our own vulnerability to boundary violations and see them as the province of a few who have nothing in common with the rest of us. The facts are otherwise. In my experience both of evaluating and treating individuals charged with sexual misconduct and consulting with psychoanalytic groups about problems in their midst, it has become increasingly clear that all of us are potentially vulnerable. (116)

By the year 2000, professional organizations, regulatory bodies, and the courts had come to view patient-therapist sexual contact as strictly forbidden, as Kenneth S. Pope wrote in 2001:

The therapeutic relationship is a special one, characterized by exceptional vulnerability and trust. People may talk to their therapists about thoughts, feelings, events, and behaviors that they would never disclose to anyone else. Every state in the United States has recognized the special nature of the therapeutic relationship and the special responsibilities that therapists have in relation to their clients by requiring special training and licensure for therapists, and by recognizing a therapist-patient privilege which safeguards the privacy of what patients talk about to their therapist.

A relatively small minority of therapists take[s] advantage of the client's trust and vulnerability and of the power inherent in the

Page 27

therapist's role by sexually exploiting the client. Each state has prohibited this abuse of trust, vulnerability, and power through licensing regulations. Therapist-patient sex is also subject to civil law as a tort (i.e., offenders may be sued for malpractice), and some states have criminalized the offense. The ethics codes of all major mental health professionals prohibit the offense. (“Sex Between Therapists and Clients” 955–956)

Sexual contact with patients is illegal in about half of the states. Beginning with Wisconsin's criminalization of sex between a therapist and a patient in 1984, a number of states began to consider how they could do more than rely on organizational codes of ethics and disciplinary proceedings to address the problem. As Colman M. Herman noted in 2012, although the laws vary widely, at least 23 states now make sexual abuse of patients by clinicians a criminal act.” Herman adds that in in the early 1990s, “there was an effort to criminalize sexual misconduct by clinicians with patients in Massachusetts, but the legislation failed to pass.”

Jay S. Kwawer, the Director of the William Alanson White Institute of Psychiatry, Psychoanalysis & Psychology, pointed out to us the important difference between the American Psychiatric Association and the American Psychological Association regarding the ethics of romantic relationships with patients. The American Psychiatric Association insists that “once a patient, always a patient”: the prohibition on therapist-patient sex exists for life. That's also true of the American Psychoanalytic Association. “Sexual relations between a psychoanalyst and patient or family member, current or former, are potentially harmful to both parties, and unethical.” The American Psychological Association states that in rare cases it may be acceptable for a therapist to become romantically involved after two years. One of the reasons for this is that most of the 135,000 members of the American Psychological Association do not see patients in long-term, intensive psychotherapy or psychoanalysis. The combined memberships of Divisions 12 (Clinical), 29 (Psychotherapy), and 39 (Psychoanalysis) represent a minority of the membership of the American Psychological Association. Since most members of the American Psychological Association do little or no psychotherapy, a psychologist might meet with a patient only a few times. Consequently, there is no assumption in brief treatment, as there is in psychoanalysis, that an intense transference develops.

Arguing for an absolute and permanent ban on post-termination sexual relationships, Gabbard and Lester observe that termination is a “particularly high-risk time for the enactment of sexual longings between analyst and analysand. It is the bane of the analytic profession that practitioners must become extraordinarily close to their patients, only to lose them. Termination is a real loss for both participants. It represents the finiteness of the relationship and even the unbearable impermanence of life itself” (154).

According to Andrea Celenza, prevalence studies indicate that psychiatrists and psychologists have equivalent rates of erotic contacts with patients, with a lower incidence among psychodynamic therapists and those who provide long-term intensive psychotherapy. The explanation, Celenza speculates, is that there is a greater awareness among the latter of the “importance of clear, non-exploitative, and therapeutically oriented roles, boundaries, and responsibilities, such as maintaining the frame, the holding environment, and appreciation for transference” (Sexual Boundary Violations, 8). On the other hand, Margolis, admittedly using anecdotal evidence, estimated that the incidence of erotic contact with patients among psychoanalysts does not differ significantly from the incidence among other psychotherapists. Several of the following prominent therapists implicated in sexual boundary violations were psychoanalytically oriented:

1965: Victor Rosen

Victor Rosen, who had been elected as president of the American Psychoanalytic Association, and who was at that time married, met with a former patient at her request for a follow up consultation because of a disturbing nightmare. The ex-patient, Elise Snyder, was at the time an early career psychiatrist and psychoanalyst. She was married to a physician whom she met while in medical school prior to her graduation in 1958. Snyder stated to Evan Osnos, in his article “Meet Dr. Freud,” published in The New Yorker on January 10, 2011, that during a consultation interview, Rosen, appearing not to be listening to her, suddenly blurted out, “I'm in love with you. I've been in love with you for the past two years” (54).

An earlier alternative version of the story of how the relationship changed from psychoanalyst and ex-patient to lovers appears in Hollywood

on the Couch, based on an account from Rosen's daughter, Winifred Rosen. According to Farber and Green, Rosen hired Snyder, after her analysis with him ended, to edit a paper he had written; “within a few months their relationship had turned into a full-fledged romance” (207). Believing that her father was “completely blind” to his own breach of ethics, Winifred Rosen reveals perhaps the strangest detail of the situation. When she told her father after she graduated college that she wanted to enter analysis to explore the issues raised by her parents' separation, he recommended that she seek treatment from Elise Snyder. “My dad didn't want me talking about the situation to an outsider,” she stated to Farber and Green. “He didn't want any of this to be known. So he sent me to Elise, which was completely weird.” Winifred Rosen said that her sessions with Snyder were “indescribable,” adding, “My father was in love, so he was insane by definition” (Farber and Green 207). Finally, to illustrate the weird entanglements that can occur in the small world of psychoanalysis, Snyder's husband was, at the time she left him, a psycho-analytic patient of David Rubinfine (see below), who himself later married a high profile patient (Personal communication, Judith Schachter, September 25, 2014).

After leaving their respective spouses, Victor Rosen and Elise Snyder were married in 1965. The news of the marriage created a major scandal in the profession augmented by the high status Rosen held at the time. He consequently left his position at the New York Psychoanalytic Institute. The marriage turned out to be unhappy and ultimately tragic. Snyder discovered that Rosen was addicted to narcotics, and after seven years she decided to leave him. He was found dead in his car the next day from an overdose of narcotics and sedatives (Osnos, 54).

Snyder herself gained recognition in her career as a psychoanalyst and eventually was nationally elected to the board of directors of the American Psychoanalytic Association. When she ran for president of the Association, however, her political opponent's supporters attempted to cast aspersions on her character, claiming that she had committed a “boundary violation” by marrying her analyst, seemingly oblivious to the fact that it is the analyst's responsibility, not the patient's, to avoid such entanglements.

The Victor Rosen case occurred in the mid 1960s, two decades before

Kenneth S. Pope and Jacqueline C. Bouhoutsos authored Sexual Intimacy Between Therapists and Patients . The book's publication, Martin H. Williams remarked in his 2011 online article “Therapist-Patient Sex Twenty Years Later: A View from the Courtroom,” marked the end of an era: “an era during which famous and respected psychotherapists married their patients, during which a surprisingly large number of psychotherapists became sexually involved with their patients, and an era during which this could be done without adverse repercussions to the therapists' careers.” Williams, a forensic psychologist who has testified as an expert witness in many sexual boundary violation malpractice cases, believes that beginning in the 1980s, the decade which brought with it a new climate of zero tolerance for sex with patients, all psychotherapists have been exposed and re-exposed to educational messages that sex with a patient is “indefensible, inexcusable and is professional suicide.” Perhaps, yet the following four high-profile cases occurred after the 1980s:

1992: Edward M. Daniels

Edward M. Daniels, a one-time president of the Boston Psychoanalytic Society and Institute, and a faculty member at Harvard Medical School, was accused in 1992 by four female patients of having engaged in sexual relations with them during their treatment in the 1960s and '70s. A hearing officer wrote in his decision that all four women were “believable, credible and truthful.” The charges led to revocation of his medical license (Daniels vs. Board). Daniels seemed to be intent on putting his patient/victims in a subservient position. One testified: “Dr. Daniels used condoms. And he insisted that I buy those condoms … that was one of the most humiliating parts of the whole thing for me … because I was very embarrassed and very terrified to walk into drugstores to have to buy condoms.” The same patient testified that Daniels would put the condoms into a Kleenex, wad them up, and then give them to her so that she would go into his bathroom and flush them down the toilet. “And he stood there to watch to make sure I did it, but he never walked out with them himself” (Wohlberg, 337, Pinsky, 360).

Alison Bass reported in the Boston Globe on May 15, 1992 that some Boston mental health professionals criticized the state's regulatory agencies for taking more than 20 months to discipline Daniels. “‘I'm delighted

the board is getting around to doing something about a situation that to us was pretty clear two years ago,’ said Dr. Elizabeth Reid, past president of the [Boston] Psychoanalytic Society. ‘What this shows is that the board needs better funding, so it can deal with these important situations in a timely manner.’” What makes the story so ironic and disturbing is that Edward Daniels had chaired the committee that wrote the ethics code for the American Psychoanalytic Association (Fall Meeting, , 423). Judith Schachter, who was president of the American Psychoanalytic Association from 1994–1996, told us that Daniels had threatened to sue the organization if he was expelled. The threat did not prevent his expulsion (Personal communication, September 25, 2014). After the revocation of his medical license, Daniels continued to practice psychotherapy in Massachusetts, a state that did not require at the time a license to practice psychotherapy. Daniels died in 2004.

2001: William A. Kadish

William A. Kadish, a graduate of the University of Chicago and the Yale University School of Medicine, and the medical director of psychiatry at Marlborough Hospital in Massachusetts, had his medical license revoked in 2001 after being accused of having sex with a patient he had been treating for multiple personality disorder. According to the accuser, Kadish slept with two of her 20 different personalities on the theory that he could help her by recreating a childhood trauma (Lasalandra). In addition, Kadish “took nude photographs of a female patient and had her snap one of him as he lay sprawled beneath his framed degree from the Yale University School of Medicine wearing nothing but a black condom that read “lollipop,” as Gretchen Voss reported in Boston Magazine in July 2005.

2005: Ralph Engle

Ralph Engle, a former chair of board on professional standards of the American Psychoanalytic Association, and at the time, chair of the Association's ethics committee, surrendered his medical license after admitting to an undisclosed “boundary violation” with a female patient. He was also a training and supervising analyst at the Boston Psychoanalytic Institute, a training facility approved by the American Psychoanalytic Association (Voss).

How do we explain the hypocrisy of those, such as Daniels and Engle, who serve on a professional ethics board while at the same time or at a later date engage in their profession's most abhorrent ethical violations? Are they, to begin with, aware of their hypocrisy? Do they decide to serve on ethics boards as a protection against later violations, a way to transgress with impunity? Are they so narcissistic that they believe they are entitled to break the rules? Are they masochistic, engaging in reckless, self-destructive behavior because of the unconscious wish to be punished? Celenza notes in Sexual Boundary Violations that the “one-time offender (usually narcissistically needy, lovesick, or from the masochistic-surrender category) is the most prevalent type of sexual boundary offender” (10). She also observes, however, that the “psychopathic predator probably accounts for the largest number of victim/patients” (135). Some psychopathic predators, as we shall see, were among the leaders in their fields, and their transgressions damaged not only their patients but also their professions. As Pope wrote in “Therapist-Patient Sex as Sex Abuse” in 1990,

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. (233)

2012: Henry Smith

Henry Smith, another Boston psychoanalyst, was sued in 2010 by a patient he had seen from 2005 through 2009 and by her husband, both of whom claimed that starting in 2006, Smith had sexual relations with her multiple times. Smith surrendered his medical license in 2010 to avoid professional discipline. In his defense, he claimed that the sexual

relationship, which he admitted had taken place, had done “no harm” to the patient. He also implied that his actions were acceptable because the patient was not “mentally ill” and that she was a “nationally respected psychologist” who was “well versed in the issues of transference,” a rationalization that all the professional psychoanalytic, psychiatric and psychological associations, which categorically ban sex between a therapist and patient, would reject. At the time, Smith was the editor of the prestigious journal Psychoanalytic Quarterly, had served as associate editor of the Journal of the American Psychoanalytic Association, and had served on the editorial boards of at least three other publications in the field. He was a training and supervising psychoanalyst at the Psychoanalytic Institute of New England, East, another training facility approved by the American Psychoanalytic Association (C. Herman).

Sex with Celebrity Patients: David Rubinfine and Elaine May

David Rubinfine was a rising star in the New York Psychoanalytic establishment in the early 1960s. As a psychoanalyst he involved himself personally and professionally with a wide array of personalities from the arts. He was appointed as a training analyst at the conservative New York Psychoanalytic Institute at the unusually young age of 40. At the time that the famous comedienne Elaine May began analysis with him, Rubinfine was married with three children and was 11 years older than May. Losing her father at age 11, May dropped out of high school at age 14 and married for the first time at 16. Ironically, at the time Elise Snyder had left her husband to marry Victor Rosen, her husband, Art Snyder, was in analysis with Rubinfine. As Rubinfine's analysis of May went on, a mutual love relationship developed between them. After presumably informing his wife, Rosa, of the situation, he moved out of their home. Shortly thereafter, on April 30, 1963, Rosa committed suicide. Rubinfine married Elaine May on June 8, 1963. The marriage lasted for 17 years until Rubinfine's death due to a heart attack (Farber and Green, 201 ff.).

Janet Malcolm doesn't mention Victor Rosen or David Rubinfine by name in Psychoanalysis: The Impossible Profession , but there's little doubt, as Farber and Green suggest, that she had them in mind when she referred to Analyst X and Analyst Y, the former a past president of the American Psychoanalytic Association who married a patient, the

latter a man who became involved in a “messy triangle during the analysis.” “The transgressions were instantly disciplined,” notes Malcolm, summarizing the sharp disapproval of “Aaron Green,” the New York analyst whose life and work she features in her book. “[T]hey were removed from the roster of training analysts, they were divested of their various functions in the ruling structure, they were dismissed from their teaching posts. Their careers in the higher reaches of establishment psychoanalysis [were] over” (92). In her next book, In the Freud Archives, Malcolm quotes Elise Snyder about the difference between the Western New England Institute in New Haven, of which she is a member, and the various New York institutes: “It is very gentle and sweet up here. It's incredibly different from the New York group, which suffers from paranoia of a high degree” (56).

Frederick J. Duhl and Anne Sexton

The psychiatrist Martin Orne treated the poet Anne Sexton from 1956–1964, but when he announced he was leaving Boston, she saw a new psychiatrist and began having sex with him almost immediately. “My therapy is degenerating to SEX,” Sexton wrote to a friend in early 1964 (231). Under pressure from his wife, he ended therapy with Sexton in 1969, when she underwent the trauma of changing psychiatrists again. The Pulitzer Prize-winning poet committed suicide in 1974 at the age of 45, an event long foreshadowed in her poetry. Sexton's biographer, Diane Wood Middlebrook, refers to the psychiatrist in question as “Dr. Zweizung,” a wry pseudonym that means “forked tongue” in German. Sexton saw the psychiatrist, who had completed his psychoanalytic training, twice a week. She called him her “doctor-daddy” (258), a possible recognition that her affair was forbidden and transgressive, symbolic incest, a repetition of her relationship with her father, who, according to Middlebrook and others, may have sexually abused his daughter when she was a child. Maxine Kumin, Sexton's close friend and fellow poet, was indignant over the affair with the therapist. “Imagine paying to get laid twice a week!” (259).

Alessandra Stanley's review of Middlebrook's biography in the New York Times on July 15, 1991, was the first to reveal the identity of Sexton's psychiatrist, Frederick J. Duhl. He refused to comment in a telephone interview with Stanley on the biography's revelations other than to say,

“You are dealing with an explosive subject; basically any doctor who has an affair with a patient loses his license in Massachusetts.” Barbara Schwartz, a psychiatric social worker who treated Sexton during the last months of her life, told Stanley that Sexton had asked her in 1973 to attend a conference with her at which Duhl was speaking. “She wanted to stand up there and say, ‘J'accuse!‘…. I felt I could not go to that meeting and let her expose herself that way.” Sexton's on-and-off-again sexual relationship with Duhl continued for years. After spending an evening with him in Washington in 1969, Sexton wrote an anguished letter to Orne in which she contrasted her trust in her former psychiatrist, who had never sexualized therapy, with her mistrust in Duhl, who had. “He promised he'd never leave me but now he tells me it depends on how he works things out with his wife. I told him if we worked together we could keep it just therapy (after all we'd had our fling in Washington)…. I pled with him. But he just said he'd see” (Middlebrook, 316).

“Anne Sexton was a very difficult person to treat,” Orne told Samuel M. Hughes in an interview published in the Pennsylvania Gazette in December 1991. “She was very seductive. But you know, if you can't deal with that, you should not be a psychiatrist.” Orne knew how to respond to her provocative behavior. Duhl didn't. He alone was responsible for her therapy degenerating to sex. He should have recognized her transference-love for him and his own countertransference-love for her, which ultimately destroyed their therapeutic relationship.

Alan A. Stone does not discuss Duhl in Law, Psychiatry, and Morality, but in his typology of therapists who have sex with their patients, Duhl falls into the category of those psychotherapists who exploit a patient's positive transference by telling her about their own problems. “Often there is talk of divorce and of marrying the patient. It is a scenario not confined to the psychotherapist's office” (211). The worst part of the sexual boundary violation for Sexton was that it was inevitably responsible for the end of therapy, which she experienced as another form of rejection and abandonment.

Frederick Duhl died in 2011 at the age of 81. An obituary published in the San Antonio Express-News on January 4, 2011 described him as a native New Yorker and a graduate of Columbia University College of Physicians and Surgeons. The obituary briefly mentions Duhl's sexual

relationship with Sexton that “blemished” his career. “He never forgave himself,” his second wife, Verne Lee Cooper admitted. “He said he betrayed his own honor.”

Khristine Eroshevich and Anna Nicole Smith

Khristine Eroshevich, a California psychiatrist who was prescribing medication for Anna Nicole Smith, was accused of having been sexually involved with the well-known sex star. The Los Angeles Times reported that photographs found on Smith's computer after her suicide in 2007 showed her nude in a hot tub with the psychiatrist. The full nature of the relationship between Smith and Eroshevich is unclear because despite the prescriptions, written using several pseudonyms for the patient, Eroshevich kept no medical records regarding Smith. In October 2012, a California appellate court ruled that a judge erred when he overturned the convictions against Smith's lawyer and psychiatrist in a trial arising from the actress's death from prescription drugs.

There are relatively few examples of “celebrities” having been sexually abused by therapists, although there is no reason to assume such cases are rare. One legal scholar, Patricia M.L. Illingworth, argues against criminalizing therapist-patient sex, wondering whether the cost of using the criminal law as a way to support private remedies may be too high. “At some point, especially with respect to celebrities and other well-off members of society (like doctors), it will just be too costly for them to have their day in court and exercise their right to a trial. If the threat of criminal sanctions means more to those who have more to lose, then they—although innocent—may be forced to settle and forfeit their right to a trial” (, p. 414).

Society's response to these transgressions has been relatively weak. In many instances, although the perpetrator gave up his medical license to practice psychotherapy as a physician, he continued to practice as a “psychotherapist,” as Edward Daniels did. Medical licensing bodies have no control over such practitioners in most states. Many of those accused, including practitioners who actually admit to their misconduct, are not forced to close their offices, as William F. Hammond, Jr., observes. One of the practitioners we describe in the following chapters lost his physician's license but continued to practice as a “hypnotist”; one lost his license but continued to practice as a therapist; one surrendered his

license and retired; and another, a Canadian, was sentenced to a substantial jail term, but an appeals court overturned the guilty verdict, and in a second trial, the psychiatrist was acquitted of all charges. As an article published in the Frederick News-Post on April 7, 2013 suggests, only 23 states have criminalized patient-therapist sex. The practice of psychotherapy has been regulated in the State of New York only since 2001.

Legal Issues

Legal scholars have raised constitutional questions about therapist sexual misconduct regulations, particularly prohibitions after the end of therapy. In a 2009 article published in the UCLA Law Review, S. Wesley Gorman remarks that many state constitutions recognize rights of sexual autonomy that are burdened by categorical bans on sexual relationships in therapy. Gorman, a Senior Editor at the UCLA Law Review, proposes a standard of sexual conduct that is based on the psychotherapist's fiduciary responsibility, which obligates the therapist to advance a patient's welfare on all matters related to professional treatment. Gorman admits that his proposed model has two shortcomings: “It's more ambiguous than a categorical ban, and it has a narrower scope” .

Some mental health professionals have debated lawyers about sexual misconduct regulations. The psychologist S. Michael Plaut, a member of the University of Maryland School of Medicine, wrote a tongue-in-cheek “Statement of Informed Consent for a Sexual Relationship Between a Health Professional and a Client or Patient.” Initially reluctant to share the document with victim/survivors, Plaut was persuaded to disseminate it to both therapists and patients. Anyone who reads the two-page document will recognize the harm of therapist-patient sex. “I understand that a sexual relationship with this Provider may ultimately have extremely damaging consequences for me including, but not necessarily limited to, feelings of betrayal, helplessness, anger, confusion, guilt, and depression, that these feelings could result in a need for psychiatric care beyond that which may have been necessary in the past, and that these feelings could possibly result in my suicide” (Plaut).

Svengali

Therapists who are psychopathic predators and have sex with many

patients over a prolonged period of time have been called Don Juans, but they are also Svengalis. To appreciate the extent to which transgressive therapists are Svengali-like, one must be familiar with George du Maurier's Trilby, which became an immediate bestseller when it was published in the United States in 1894. The novel's heroine, Trilby O'Ferrell, is a poor young laundress in Paris who aspires to become a singer, a dream that the conductor Svengali promises to transform into a reality.

Svengali hypnotizes the tone-deaf Trilby, who is magically transformed into a diva with a golden voice, La Svengali. But her success depends upon hypnotic suggestion, akin to mesmerism, as a friend futilely attempts to warn her. “He mesmerized you; that's what it is, mesmerism! I've often heard of it, but never seen it done before. They get you into their power, and just make you do any blessed thing they please lie, murder, steal anything! and kill yourself into the bargain when they've done with you!” (52). The spell is broken when Trilby performs under a substitute conductor during her debut London concert. Losing her angelic voice, the audience jeers her, and Svengali unexpectedly dies of heart failure. Later, Trilby can hardly believe her behavior while under his evil spell, and she dies at the end of the novel, purified of guilt and shame.

Svengali's ability to exploit and dominate Trilby derives in part from her traumatic childhood. The daughter of alcoholic parents whose deaths have left her bereft, she was sexually abused by one of her mother's friends. Trilby is forced to model in the nude to support her illegitimate younger brother, whose death from scarlet fever shatters her. These losses heighten Trilby's vulnerability, enabling Svengali to take advantage of her. Svengali is himself self-abasing, hypersensitive, intensely jealous. Svengali is a musician, not a therapist, but he has the power to heal Trilby's psychic wounds both by convincing her she is “special,” a word that is almost always used in sexual boundary violations stories, and by promising to marry her—though he was married to another woman with whom he had three children, all four of whom he deserted. Trilby becomes Svengali's imagined wife, slave, pupil and disciple. His sinister love for her represents a source of endless torment.

Elaine Showalter observes, in her introduction to the 1998 Oxford edition of Trilby, that Svengali, whom du Maurier describes as an “Oriental

Israelite Hebrew Jew” (244), “stands alongside Shylock and Fagin in the annals of anti-Semitic literature” (ix). Writers who use the expression “Svengali-like” to characterize an analyst's hypnotic and seductive influence on a patient are not necessarily referring to a Jewish analyst, though as Edward Shorter notes in A History of Psychiatry, by the late 1950s, 80% of American psychoanalysts were Jewish (186). As we shall see later, several people used the expression to describe the Jewish analyst Gregory Zilboorg, who upon his entry to the United States became a Quaker and then later in life converted for a second and final time to Catholicism.

The term “Svengali-like” is particularly apt with respect to analysts who use hypnosis, suggestion and charisma as part of their treatment. Showalter reminds us that in the same year that Trilby was published, Freud was writing about his hypnotized patient Emmy von N., one of several case studies appearing in Studies on Hysteria . Trilby is a fictional character, but she could easily exist within the pages of Studies on Hysteria. She mysteriously loses the will to live at the end of the novel, and her English physicians are baffled by her illness.

Du Maurier's novel has become a lightning rod for those who believe that psychotherapy is a cult and a hoax, and that Freud was a manipulative Svengali whose patients were in the position of a helpless Trilby. Without endorsing this caricature, Daniel Pick remarks in Svengali's Web: The Alien Enchanter in Modern Culture that the “predicament, real or imagined, of the gullible client influenced by the devious ‘Svengalian’ therapist persists as a stock talking point in much current media conversation of the ‘healing arts.’ Of course, manipulation, suggestion and interference may well operate in fact, rather than just in paranoid cultural fantasies” (218). The word “Svengali-like” appears in many sexual boundary violation stories to describe an analyst's seductive power over a patient. The reader's challenge in these stories is to determine whether the patient's predicament is real or imagined and whether the therapist is indeed a Svengali.

Seductive Patients

Elissa Benedek recommended, in her capacity as president of the American Psychiatric Association, that therapists who find themselves sexually attracted to a patient should seek help themselves or refer

their patient to another therapist (Slovenko, Psychiatry in Law/Law in Psychiatry, 609). This sounds like good advice, but if psychotherapists followed that recommendation strictly, there would be a dire shortage of clinicians to treat their sexually aroused colleagues. How can one expect “purity” in a profession charged with erotic fantasies and desires?

Moreover, psychoanalysis has a long history of interpreting claims of seduction as originating from fantasies rather than reality. In the chapter on “Female Masochism” in her two-volume study The Psychology of Women , Helene Deutsch asserts that both seduction and rape fantasies “often have such irresistible verisimilitude that even the most experienced judges are misled in trials of innocent men accused of rape by hysterical women” (vol. 1, 256). These fantasies, Deutsch adds, are often produced by women's “masochistic yearnings.” In The Assault on Truth, Jeffrey Moussaieff Masson argued misleadingly that Freud abandoned the seduction theory because of his intellectual fear in acknowledging the truth of his patients' statements that they were sexually abused. Contrary to Masson's claim, psychoanalysis has always tried to be attentive to the often-ambiguous intersections of reality and fantasy. It remains true, however, that some analysts may be misled into believing that a patient's report of seduction by a relative, friend, or therapist is nothing more than a wishful fantasy.

Cautionary Notes

The psychotherapy community has generally remained silent about boundary violations, embarrassed by the negative publicity, particularly when the transgressive therapist is prominent. Phyllis Greenacre's comments in a 1954 article published in the Journal of the American Psychoanalytic Association are worth recalling. “I cannot in the least agree with the remark of a quite eminent analyst, repeated to me several times, that so many analysts overstep the boundaries of the transference even in grossly sexual ways that therefore the best thing to do is to say nothing about these incidents. It is only by discussing these possibilities (rather than by punishing the offenders) and by emphasizing their dangers to students and among ourselves that we can really develop our science to the research precision which must be aimed at in each clinical case” (681). Greenacre's recommendation that transgressive therapists should be free from professional discipline or the loss of their licenses

may surprise us; yet we must remember that few if any mid-20th century psychiatrists or psychoanalysts were censured as a result of a sexual or nonsexual boundary violation. But if part of Greenacre's observation now seems dated, the essence of her remark about the extent to which transference-love reproduces the parent-child relationship remains as timely as ever. “For this very reason, the carrying through into a relationship in life of the incestuous fantasy of the patient may be more grave in its subsequent distortion of the patient's life than any actual incestuous seduction in childhood has been.” Psychoanalysis is a “hard taskmaster,” Greenacre continues. “The power of the unconscious is such that it ‘gets back’ at those who work with it and treat it too lightly” (684).

In considering the complex and painful subject of sexual boundary violations, the following caution should be kept in mind. Although the authorities we have cited, from Freud onward, have been inclined to attribute the sexual peccadilloes of psychotherapists in general and psychoanalysts in particular to the complex and intense transferential relationship that the psychoanalytic situation engenders, there is another way of viewing this history and ongoing problem. As we mentioned, surveys of psychotherapists have placed the number of therapists who have admitted to sexual relations with patients in the 7–12% range, mostly due to male therapists becoming involved with female patients. However, a survey of attorneys using a similar technique found the number of attorneys who admitted to sexual involvement with clients at about the same percentage (Murrell). Most of these cases involved a male attorney with a female client who was going through a divorce (Livingston). Sexual involvement with clients, even with the client's consent, is an absolute violation of the ethics of the legal profession with the single exception of a sexual relationship that was in existence before the attorney-client relationship was initiated.

Greenacre's observation that transference, based on a primitive “mother-child relationship,” promotes in the patient “an attitude of expectant dependent receptiveness toward the physician” (672), leads immediately to a consideration of the worldwide scandal among Roman Catholic clergy. Catholic priests' widespread sexual abuse of children reached a peak in the 1970s, an era in which many of the examples of sexual misconduct by psychotherapists also took place. Since the sexual abuse of children seems to trigger a higher degree of outrage than therapists'

sexual interaction with (supposedly) consenting adults, it might seem odd to compare these two phenomena. However, when one considers that many adult patients slip into a dependent child-like state with their therapist, a development which therapy is structured to promote as a necessary element in the process, it becomes clear that the comparison is apt. The priest scandal grew so large that the Roman Catholic Church was eventually compelled to pay out about one half billion dollars in worldwide settlements, leading to the bankruptcy of several Church institutions.

As to the magnitude of these two phenomena, comparison is difficult because the data-gathering methods in the two instances are not comparable. As we have seen in the case of psychotherapists, estimates of the prevalence of sexual misconduct with patients have been based on anonymous surveys of psychotherapists. By contrast, estimates of sexual abuse of children among the priesthood are based on comprehensive surveys of the number of priests against whom complaints were made as the Church's intent to take this problem seriously crystallized in the early 2000s. The United States Conference of Catholic Bishops commissioned the John Jay College of Criminal Justice of the City University of New York to study the question. The college produced two reports, the first to document the Nature and Scope of the abuse problem , the second to document the Causes and Context of the problem . Findings from these studies indicate that the percentage of priests involved is such misconduct appears to be about the same order of magnitude as analogous misconduct by male psychotherapists during the same era. Of the priests ordained in a given year, the statistics vary from a high of about 10% in 1970, to 8% in 1980, to a low of about 4% in 1990 (Nature and Scope of Sexual Abuse, 27). These results are reasonably consistent with the earlier results reached by A.W. Richard Sipe, a psychotherapist and retired (and married) ordained Roman Catholic Priest. Sipe concluded that the incidence of sexual abuse of minors was approximately 6% based on data available to him at that time (27).

Contrary to what many might believe, fewer than 5% of the accused priest-offenders were pedophiles. The priest-offenders were in their psychological characteristics not distinguishable from others in the priesthood. The majority of accused priests in treatment also reported sexual behavior with adult partners. “Sexual behavior in violation of the

commitment to celibacy was reported by 80 percent” of such priests, “but most sexual behavior was with adults.” It appears that the sexual abuse of children by priests was for the most part because the youngsters involved were “targets of opportunity” for a group of individuals inclined to engage in sexually deviant behavior in general and who encountered children in their roles as teachers, coaches, and counselors (Causes and Context of Sexual Abuse, 3).

It is therefore reasonable to wonder whether the particularities of psychotherapy are responsible for the number of boundary violations that are thought to occur, or whether the more important factor, present in the psychotherapy profession, the legal profession and the priesthood, should be mainly attributed to character deficits among the involved practitioners in combination with intense transferences that can exist in all these relationships.

Writing in 1997, M. Margolis wondered why the incidence of sexual boundary violations by psychoanalysts appeared similar to the incidence among other psychotherapists, despite the additional training and personal analysis required by psychoanalysts. (Celenza, we recall, believed that the incidence of sexual boundary violations by psychodynamic therapists is lower than that of other therapists, but she was writing a decade later, when the prevalence studies might have changed.) Margolis implied that the analyst's additional training and personal analysis are cancelled out, as it were, by the more intensive relationship:

We pride ourselves on our stringent admission policies for training, longer periods of professional education and commitment to personal treatment as a safeguard against sexual exploitation of patients. Some of us therefore conclude that we are not so troubled by this phenomenon as other mental health professions. With all due respect to the importance of such selection and training standards, we should not overvalue the role of such factors. Perhaps our deeper involvement and immersion in the dark depths of patients' psychic lives expose us to greater temptation. We are therefore vulnerable in a special way, as well as sharing the vulnerabilities of therapists from other less intensive therapies. (Margolis, 352)

Additionally, such transgressions are thought to have a different meaning

when they take place within the context of a psychotherapy in which the understanding and management of transference are core components of the therapist's work. In such a treatment, a sexual interaction between the therapist and the patient becomes more than unethical, as it would be considered in all forms of psychological treatment nowadays. It also constitutes a technical failure in management of the transference, a major requirement of the therapist and the therapy, and therefore is both more serious a violation and, arguably, an act of negligent malpractice (Bates and Brodsky, 133; Stone, Law, Psychiatry and Morality, 203).

Preventing Boundary Violations: An Optimistic or Pessimistic Outlook for the Future?

No one has written more incisively about boundary violations in psychoanalysis than Glen O. Gabbard, and it is instructive to compare his two editions of Boundaries and Boundary Violations in Psychoanalysis. In the first edition, co-authored with Eva P. Lester and published in 1995, Gabbard refers hopefully to the “sea change” (xii) that has occurred in recognizing the seriousness and prevalence of sexualized therapy. He remains cautiously optimistic throughout the book that the problem of sexual transgressions can be effectively addressed. In the second edition published in 2016, however, he has become more pessimistic. The problem of sexualized therapy remains despite greater institutional awareness and improved reporting. Sexual transgressions with patients continue to occur on a regular basis, Gabbard notes gloomily, “often among analysts and therapists who are well regarded and thoroughly familiar with the risks and dynamics of boundary issues. As a result, I have become increasingly pessimistic about our capacity to prevent the occurrences of sexual relations between individuals who practice psychoanalysis and their patients. I am even more pessimistic about preventing nonsexual boundary violations, which are nevertheless destructive and exploitative in light of their capacity for rationalization.” The reason for Gabbard's pessimism? “The capacity for self-deception is extraordinary” (151).

To solve a problem, one must first acknowledge the magnitude of its seriousness, and Glen Gabbard and others continue to call attention to the sexually transgressive psychoanalyst. In “Rotten Apples and Ambivalence: Sexual Boundary Violations Through a Psychocultural Lens” (Journal of the American Psychoanalytic Association, ),

Muriel Dimen captures the ways in which the problem threatens the entire institution of psychoanalysis. Writing as a trained psychoanalyst, anthropologist and self-admitted “whistle-blower,” Dimen—who died as her paper was being prepared for publication—shows how sexual transgressions “generate a great and contagious anxiety prompted by how they pollute and stigmatize anyone and anything in their vicinity” (362). Sexual boundary violations are a social as well as a psychological problem, she suggests, and they result in the group's “muteness.” In his commentary on Dimen's paper, Gabbard notes that sexual boundary violations are the “Achilles' heel of the psychoanalytic profession” (“The Group as Complicit in Boundary Violations,” 379), a statement that applies to the entire mental health profession.

Behind the Couch

To return to the image of the lovesick analyst with which we began this chapter, few therapists have not been sexually or romantically attracted to a patient, “seductive” or not, during their careers. How should ethical therapists behave in this situation? Herbert S. Strean discusses this question in Behind the Couch: Revelations of a Psychoanalyst, co-authored with Lucy Freeman . “Rarely does an analyst talk about his erotic fantasies when an attractive woman on the couch tells him he is the most desirable man in the world,” Strean confesses early in the book (23). Strean is one of the few men—there are even fewer women—to write about an analyst's attraction to a seductive patient. In the chapter “Sometimes I Feel Like a Dirty Old Man: The Woman Who Tried to Seduce Me,” he discusses “Susan Brown,” a woman who had sexual affairs with three different therapists. Her wish to turn her therapy sessions into a torrid if fleeting love affair, a “coup on the couch” (72), proves to be a challenge to Strean, who struggles with his own desire for her. “I felt I must be something of a Romeo if a woman as beautiful as Susan wanted me sexually. But as stimulated as I felt, I constantly reminded myself of how she used sexuality as a means of manipulation, a way of buttressing her shaky self-image and precarious self-esteem” (81).

Strean recounts, with self-lacerating humor, Susan Brown's rage when he refuses her various ploys to seduce him. At one point she threatens to leave him to find a “more potent” therapist. He describes his own retaliatory anger when she misses three sessions in a row, leaving a message on

his answering machine, “You no-good son of a bitch. You have an icy personality. You sure are a cold potato” (75). By refusing to gratify her sexual wishes, Strean helps her to understand how she was projecting onto him her ambivalent feelings toward her father, whom she felt had stimulated her but then withdrew from her life. Sex on the analyst's couch, Strean concludes, leads inevitably to betrayal, a statement with which no 21st century psychotherapist would disagree. Not all of Strean's statements are factually accurate. He cites D.H. Lawrence's erotic novel Lady Chatterley's Lover, rather than Philip Roth's psychoanalytic monologue Portnoy's Complaint, as an example of a patient's outpouring of comments that has the effect of silencing an analyst. Despite this mistake, Behind the Couch reminds readers that ethical mental health professionals do not use sex as a guise of therapy.