Background: Research evidence on unprofessional relationships across the caring professionsc onsiders a range of activities and definitions (Halter, Brown & Stone, 2007). The evidence on sexual boundary violations (SBVs) in psychological...
moreBackground: Research evidence on unprofessional relationships across the caring professionsc onsiders a range of activities and definitions (Halter, Brown & Stone, 2007). The evidence on sexual boundary violations (SBVs) in psychological therapy is sparse, but suggests that SBVs are under-reported; there is also a small but significant component of complaints. Conversely an increasing literature exploring client experience of SBV suggests that the effects are profound (Ben-Ari & Somer, 2004; Somer & Nachmanil, 2005). The prevalence literature is primarily quantitative, often using survey methodology. Conclusions have limited accuracy; there are issues raised, for example, when considering recruitment and sample characteristics, response rates, and questionsand definitions used. Some studies identified general characteristics associated with SBVs, including middle age, being male, working alone and outside the public sector; more recent literature, however, has been critical of the notion of the 'bad apple'. Halter, Brown and Stone (2007) conclude that provision of information is insufficient; evidence for the effect of recent innovations in training is promising, but evaluation of these is necessarily limited. It is unlikely, however, that UK accredited practitioners are ignorant of the code of ethics to which they have signed up; other reasons are more likely to play a part in sexual boundary violations.
Research Aims and Questions: The aims of the current research were to (1) Identify the indicators that signal potential or actual sexual boundaryviolations by healthcare providers who are relevant to the remit of the British Association for Counselling and Psychotherapy; (2) Explore how practitioners manage these in their therapy work and the effects of such management strategies; (3) Make detailed recommendations to minimise risk of sexual boundaryviolations by such healthcare providers.
Methodology: Thirteen practitioners were interviewed about their experiences of managing the risk of sexual boundary violations. Inclusion criteria were: accreditation as a counsellor or psychotherapist within specified counselling or psychotherapy organisations; a preparedness to confirm that he or she had not committed, or been subject to an investigation concerning, a sexual boundary violation; extensive experience of clinical work since qualifying, some of this being outside the NHS. To maximise the potential variety in participants and accounts, participation was invited through advertising and electronic distribution lists. The sample was completed through purposive sampling; to ensure that the sample varied sufficiently in terms of sex, disclosed hetero or homo-sexual orientation, age, cultural background, experience and time since qualified, working environments, therapy models, registering body and geographical location, four participants were identified through personal and professional contacts. The sample therefore included individuals from both higher and lower risk categories. Semi-structured interviews were used to elicit therapist experiences. The focus was on gaining detailed accounts of boundary breaches and potential SBVs, on reactions,choices and strategies adopted by practitioners, and opinions and judgements. Data were analysed thematically (Miles & Huberman, 1994; Braun & Clarke, 2000), each interview analysed initially by pairs consisting of an academic and a clinician. Principles of Free Association Narrative (Hollway & Jefferson, 2000) were employed when extending the analysis beyond the participan's opinions and explicit themes, using the interviewer's experience to understand the complexities of the constructed account.
Findings: Participants described SBV as one extreme on a continuum of boundary breaches; many accounts focussed on recognition and management of small breaches. Experiences of sexual attraction originating from client and therapist were seen as ubiquitous and unavoidable, and occurred without reference to sex of therapist and client, or sexual orientation; the management of the experience was seen as critical in determining whether a serious breach had taken place. Definitions of breaches and boundary violations varied, especially in views on touch. The key factor identified in definitions of boundary breaches concerned motive, i.e. whether the practitioner was acting in their own interests rather than for the client's benefit. For some, boundaries and their management, including sexual boundaries, were integral to therapeutic work. Elements of the steps involved in the therapeutic management of boundaries were developed into a process model created through analysis of what seemed to work positively for therapists and clients. The model articulates the following process: (1) noting; (2) facing up to it personally; (3) reflecting; (4) processing; (5) formulating; (6) working for therapeutic benefit. This model represents an ideal; therapists viewed the process as an ongoing struggle. Practitioners described a tension between engagement and sense making; we came to view this as a participant/observerstance, with similarities to Celenza's (1995) definition of empathy. Some accounts of managing boundaries were deemed problematic, even though they were not descriptions of sexual boundary violations, by participant or research team; for example, the strategies adopted for managing pressure on therapeutic boundaries sometimes resulted in distress to clients and difficulties with therapeutic work. These were grouped into a typology of four categories: self-protective/defensive; moralising/omnipotent; neediness/over-identification, and over-protective anxiety. A feature of all examples was a difficulty in maintaining a constructive balance between participation and observation. Supervision was seen as the primary source of support for successfully managing boundaries; we focussed on experiences of supervision and views of its functions. Supervisors were expected to focus on client benefit, manage the supervisory relationship, facilitate understanding, and an ethical and therapeutic stance. These mirror the practitioner's roles, so that supervisors might support therapist work at any point. One of the major aims of supervision seemed to be the development of an internal supervisor (Casement, 1985). Additionally, supervisors were expected toprovide quality checks, monitoring the therapist's account and their own experience, speaking of difficulties, so that threats of boundary breaches could be discussed. This extended for some to a responsibility to report serious unprofessional misconduct.
Conclusions and Recommendations: These findings are not inconsistent with the literature and research on sexual boundary violation, victims and transgressors, even though participants had avoided sexual boundary violations and had experience of successfully managing boundary threats. The sample tended to favour more conservative stances towards boundary limits such as touch; this may have been a protective factor. Recommendations for practice have been framed as issues for reflection for practitioners, supervisors, employing organisations, accrediting bodies, and training organisations. These include: increasing clarity over reporting; support during investigation; training in boundary management; supervisor contracting; formulation of practitioner learning needs; for practitioners to develop and own a rationale for therapeutic boundaries and prohibitions. There are finally suggestions for future research.
