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APA Psychotherapy Training Videos are intended solely for educational purposes for mental health professionals. Viewers are expected to treat confidential material found herein according to strict professional guidelines. Unauthorized viewing is prohibited.
Table of Contents
This material was prepared by the developers of the American Psychological Association (APA) Psychotherapy Video Series: John C. Norcross, Donald K. Freedheim, Julia Frank-McNeil, Gary R. VandenBos, and Margaret M. Schlegel. Grateful acknowledgement is made to all the participants in the series from which these vignettes were culled. Introduction A common but challenging experience in psychotherapy is a client's expression of sexual feelings toward the clinician. In a national study of 600 psychologists, for example, 73% of practitioners were told by a client that he or she was sexually attracted to them (Pope & Tabachnick, 1993). Even higher percentages of practitioners—between 87% and 90%—reported having felt sexually attracted to a client (Pope, Keith-Spiegel, & Tabachnick, 1986; Pope, Tabachnick, & Keith-Spiegel, 1988; Rodolfa, Hall, Holms, & Davena, 1994). Moreover, clients and potential clients frequently misunderstand the probable consequences of their expression of sexual interest in the therapist. In one study of 265 potential clients (Bram, 1997), nearly one fourth indicated that their therapist would have pursued the sexual interest and another 16% indicated that the therapist would have likely referred him or her to another therapist. Although psychotherapists frequently encounter sexual and loving feelings in therapeutic relationships, specific training on sexual dilemmas and boundary issues is often absent from graduate coursework for mental health professionals (Bridges, 1998). Explicit modeling and formal training in responding therapeutically to a client's sexual or romantic attraction is rare. Over one half of psychologists, for instance, reported no training in this area, and only 9% believe that they had received adequate training (Pope et al., 1986). As a result, students are inadequately prepared for the intense and intimate feelings clients may express toward them. Adding to the difficulty is the reticence and embarrassment surrounding sexual material in general. Individual clinicians are understandably hesitant to discuss the experience with colleagues or supervisors, and the entire profession, until relatively recently, has been silent on sexual feelings in psychotherapy (Tansey, 1994). When we began developing the APA Psychotherapy Video Series several years ago, we initiated numerous discussions and conducted a small survey of fellow clinicians on which in-therapy incidents they would most like to observe on video for the purposes of clinical training and continuing education. Clinicians of various disciplines and orientations rated "expresses sexual attraction toward the therapist" among the most instructive incidents. Because the overwhelming majority of psychotherapists have experienced clients' sexual attraction toward them and because these feelings can be a source of distress—and even sexual acting out—training in this area is crucial (Rodolfa, Kitzrow, Vohra, & Wilson, 1990). Purpose This stimulus training tape, created from the APA Psychotherapy Video Series, demonstrates how six psychologists respond in session to clients' expressions of sexual attraction. The vignettes were drawn from videotaped sessions in which professional actors adept at improvisation and experienced in psychotherapy portray actual clients in unscripted and spontaneous exchanges. The attraction is manifested in a multitude of ways: as direct, overt requests to extend the therapeutic frame into a romantic or sexual relationship (Vignettes 1, 4, and 5); as self-conscious, even embarrassing, expressions of sexual arousal toward the therapist (Vignettes 2 and 5); and as a confusing and distressing sexualized dream involving the therapist (Vignette 3). These vignettes are representative, but certainly not exhaustive, examples of the ways in which clients broach the topic. Of course, the psychotherapist's method of responding is specific to the context of the session and the dynamics of the client. Each of the six vignettes, between 3 and 7 minutes in length, attempts to show the content and process of the client's expression of sexual attraction, the therapist's initial responses to that expression, and some of the ensuing transaction. To illustrate a variety of therapist responses while keeping the tape to a manageable length for training purposes, we limited the amount of dialogue following the client expression of attraction. The six vignettes in this stimulus training tape were selected from the APA Psychotherapy Video Series master tapes. In some cases, the vignettes were drawn from the actual videotaped sessions; in other cases, the vignettes were drawn from additional videotaped material in the series. This video, as the title indicates, was designed to demonstrate an assortment of skilled therapist responses to a client's expressions of sexual attraction in the course of ongoing psychological treatment. More specifically, the objectives are to
Suggested Training Applications Responding Therapeutically to Patient Expression of Sexual Attraction offers a number of educational applications that psychotherapists and psychotherapists-in-training may find useful in their practice, teaching, and research. Before watching the video, viewers should be familiar with the ethical principles, professional standards, and legal statutes regarding sexual relationships between clients and therapists. The American Psychological Association (APA) "Ethical Principles of Psychologists and Code of Conduct" (APA, 2002), for one prominent example, expressly and directly states that "psychologists do not engage in sexual intimacies with current therapy clients/patients" (Standard 10.05). The ethical codes of all major mental health professions forbid sexual activity with current clients (Bersoff, 1995; Koocher & Keith-Spiegel, 1998). Furthermore, many states have now enacted criminal statutes against therapist–client sexual activity. Even though psychotherapists have a direct injunction to avoid sexual relationships with their clients, they have few other incontrovertible rules or professional standards to guide them in responding therapeutically to their clients in this arena and in handling their own feelings. All of this background information serves as a necessary context for this video. This stimulus training tape demonstrates various ways in which sexual attraction is expressed and the ways in which it may be interpreted. The client's expression of sexual interest in the psychotherapist may represent genuine attraction, displaced affect, situational stress, attention seeking, unmet needs, aggressive impulses, or any number of other motives. Several questions may be posed to assist the therapist in exploring sexual feelings from the client's perspective:
The intent of this video is to foster the therapist's self-reflective and self-observing stance. As part of these considerations, the discussion typically turns to the origins of the sexual attraction. Specifically, within the context of the special therapeutic relationship, can client sexual attraction be attributed, in part or in whole, to the "real relationship"? Or is it considered solely in terms of the transference relationship? To the extent that the attraction is "real" or "genuine," who created this complex feeling? Was it the psychotherapist, the client, or both? The vignettes of clients displaying sexual interest in their psychotherapist can fruitfully lead to a broader discussion of boundary strains in general—for example accepting gifts, attending special events in clients' lives, or participating in social activities or other extratherapeutic relationships. This video may help therapists appreciate the countertransferential feelings generated by sexual attraction directed at them. One's initial experiences with and reactions to sexual feelings may shape much of how one is able to deal with strong emotional responses. Natural reactions to sexual material may include feelings of being prized, attractive, flattered, aroused, threatened, misunderstood, or even offended. However, none of the positive feelings can be ethically actualized by the psychotherapist, and none of the negative feelings prove to be therapeutic. The fine line the therapist must walk is to provide validation for the client without acting on one's feelings. This video is primarily intended to model several means of responding therapeutically to a client's sexual attraction. The instructor or viewer may experiment with at least three pedagogical methods.
Role-playing and generating alternative responses to those displayed on the stimulus video may provoke a discussion of the psychotherapist's mutual expression of sexual attraction toward the client. Viewers should consider the following questions: "When, if ever, might you, as a psychotherapist, self-disclose that you are also sexually attracted to the client, while also indicating that you would not act on those feelings?" Teachers should then explain that ethical codes do not specifically address this question, but researchers have determined that such a response is rated by psychotherapists as less therapeutic for the client (Goodyear & Shumate, 1996) and judged by the majority of psychologists as unethical (Pope et al., 1988). Training on the personal, professional, ethical, and legal issues involved in sexual attraction between psychotherapists and clients must emphasize the difference between sexual attraction—a common if vexing part of therapeutic practice—and sexual acting out—an unethical and potentially destructive behavior. Indeed, Rodolfa et al. (1990) argued that "if that distinction is not made, honest discussion becomes virtually impossible" (p. 314). Further discussion of this topic can be found in published works on model courses for training psychotherapists in this area (e.g., Bridges, 1995; Gorton, Samuel, & Lebrowski, 1996; Rodolfa et al., 1990), on sexual feelings in therapy (e.g., Edelwich & Brodsky, 1991; Mann, 1997; Pope, Sonne, & Holroyd, 1993), and on boundary considerations in general (e.g., Gabbard & Lester, 1995). Training on handling sexual attraction must also cover clinical documentation. The consensus is that the clinician should carefully record the discussion of sexual feelings in his or her notes to document the response, in case of later misinterpretation by the clients or others (Murphy & Dillon, 1998). The documentation may also assist, of course, with supervision and consultation. Finally, these vignettes can be used to introduce and underscore the broader topic of therapist self-care. Challenging exchanges such as emergence of the client's erotic feelings toward the therapist can serve as a catalyst for the therapist's personal growth (Hayden, 1996). The line between experiencing sexual feelings and acting on them may be unexpectedly crossed if therapists fail to attend adequately to their own personal gratification. A therapist who is undergoing a divorce, death of a loved one, adult crisis, or other personal stress can potentially succumb to the fantasy that a client can satisfy the therapist's own emotional hunger (Solomon, 1997). This raises the twin imperatives of, first, seeking consultation or supervision in such circumstances (Rodolfa et al., 1994) and, second, maintaining the gratifying relationships and self-care regimens (Solomon, 1997). Questions for Consideration Following Each Vignette
Therapist Responses To maximize the training goals of the video, the series developers repeatedly watched the vignettes and sought to operationalize how the psychotherapists responded to the client's expression of sexual interest. We observed frequent types or classes of therapist behavior: acceptance of feelings, validation of the expression and the relationship, clarification and interpretation, exploration of feelings, and prohibition of acting on the attraction. Below are listed, in descriptive and theoretically neutral language, the therapist responses we identified. The categories are by no means exclusive, and the representative responses overlap. Acceptance of Feelings
Validation of Expression and the Relationship
Clarification and Interpretation
Exploration of Feelings
Prohibition of Acting on the Attraction
The six psychotherapists in this video handle the critical incident in the same, if not consensual, way. This is not to say that their particular responses are identical; indeed, considerable diversity is evidenced in terms of specific behaviors and sequences, as reflected in the foregoing list of therapist responses. Instead, there is a core commonality in how the psychotherapists respond. They encourage the expression, normalize the sexual feelings as common, state that acting on those feelings is impossible and would be contrary to the client's treatment and best interest, and reiterate the specialness and safety of the therapeutic relationship. Although several clients are disappointed with their therapist's nonreciprocation of desire, the interaction typically results in a richer and valued relationship. It is important to note that the psychotherapists behave similarly not only in how they respond but also in how they do not respond. None of the therapists belittle or criticize the client for vocalizing sexual feelings. None of the therapists ignore or avoid the attraction, although they may have been tempted to do so to alleviate discomfort. None shame, blame, or reject the client. Most important, none equivocate in saying no to the request to extend the relationship sexually or romantically. Nor do the therapists overtly exhibit shock or discomfort in their reaction to the client's admission, despite any discomfort that they may have experienced. References
Read the Guide to Using Responding Therapeutically to Patient Expression of Sexual Attraction |
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