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Report for the British Association for Counselling and Psychotherapy

Practitioners Experiences of Managing the Risk of Sexual Boundary Violations

Mary Godfrey, Institute of Health Sciences, University of Leeds Carol Martin, Institute of Health Sciences, University of Leeds Anna Madill, Institute of Psychological Sciences, University of Leeds Bonnie Meekums, School of Healthcare, University of Leeds

FINAL REPORT DECEMBER 2009

Acknowledgements
Our thanks go to the BACP for funding and supporting a study into this interesting and clinically significant area and to Sukdeep Khele (Suky), in particular, with whom we had much contact and who was helpful in so many ways. Also, we offer thanks to the staff in the Institute of Health Sciences (University of Leeds), especially Sarah Clarke and Sandra Holliday for financial and practical support, to Margaret Williams for her excellent transcriptions and to Julie Prudhoe for her administrative assistance. We are grateful to Anna Rossiter for conducting her systematic research review on a topic relevant to this research and for agreeing to her findings being incorporated into this report. We extend our thanks to Greg Nolan for conducting one of the research interviews and for engaging in the analysis of the data offered by this participant. We valued the positive response from the staff from journals who took our advertising and from the networks and organisations who distributed our information sheets. We are grateful to the group of expert clinicians who comprised our focus group, acted as advisors, and whose views shaped our approach to the data collection. We appreciate the feedback from our session chair, Nancy Rowland, and the audience at the October 2009 BACP workshop in Newcastle who reflected on an initial version of the findings. Finally, our thanks go to the participants who offered not only time, but who were generous in the extreme with their accounts of clinical activity, in their willingness to speak of their most difficult experiences and of their supervision. Each account made a unique and valued contribution

CONTENTS
Practitioners Experiences of Managing the Risk of Sexual Boundary Violations

Executive Summary Practitioners Experiences of Managing the Risk of Sexual Boundary Violations ........ Chapter 1: Introduction and Literature Review ............................................................................. Chapter 2: Method ....................................................................................................................... Chapter 3: Participants Characteristics, Motivation for Participation and Attitudes to Boundary Issues ....................................................................................................................... Chapter 4: The Therapy Work: Managing Risk ........................................................................... Chapter 5: Problematic Strategies and Creating Safe Boundaries

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Chapter 6: Supervision ................................................................................................................ Chapter 7: Summary, Conclusions and Practice Implications ...................................................... Appendix 1: Systematic Review ..................................................................................................... Appendix 2: Research into practitioners experiences of successfully managing the risk of sexual boundary violations with clients .................................................................................. Appendix 3: Consent form .............................................................................................................. Appendix 4: Flyer ........................................................................................................................ Appendix 5: Interview topic guide ................................................................................................... Appendix 6: Ethics Approval Letter ................................................................................................ Appendix 7: Transcription Conventions .......................................................................................... References ................................................................................................................

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Executive Summary
Practitioners Experiences of Managing the Risk of Sexual Boundary Violations

Background Research evidence on unprofessional relationships across the caring professions considers a range of activities and definitions (Halter, Brown and 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 and Somer, 2004; Somer and 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 questions and 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

boundary

violations 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 boundary violations 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 and Huberman, 1994; Braun & Clarke, 2000), each

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interview analysed initially by pairs consisting of an academic and a clinician. Principles of Free Association Narrative (Hollway and Jefferson, 2000) were employed when extending the analysis beyond the participants opinions and explicit themes, using the interviewers 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 clients 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/observer stance, with similarities to Celenzas (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

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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 practitioners 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 to provide quality checks, monitoring the therapists 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

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needs; for practitioners to develop and own a rationale for therapeutic boundaries and prohibitions. There are finally suggestions for future research.

Chapter 1
Introduction and Literature Review

Introduction Recent government initiatives, including regulation requirements, indicate increasing public anxiety about professional relationships in health settings. There are several types of concern, demonstrated by the Alder Hey and Shipman cases, to cite two very well publicised examples. One area for disquiet is the awareness of the potential for breaches of accepted boundaries through the development of sexual relationships between practitioners and their clients or patients. Historically, this boundary has been in place since the earliest days of psychotherapeutic work, and perhaps derives directly from the values expressed in the Hippocratic Oath. A small literature describes the personal impact of breaches of trust on the client (Alexander, 1995; France, 1998; Ward, 1993). Furthermore, many studies show how damaging sexual boundary violations can be in the therapeutic relationship for both client and practitioner (Hartl et al., 2007; Norris et al., 2003; Moggi et al., 2000). Currently, all British accrediting bodies for psychological therapists

incorporate principles and directions about the appropriate limits on relationships with clients. These include a prohibition on sexual relationships, often not only with current clients, but also with past clients. In its Ethical Framework (2007), the BACP states within Ethical principles of counselling and psychotherapy, that practitioners must make a commitment to avoiding harm to the client, including the avoidance of sexual exploitation. It further emphasises within the section Keeping trust that a clients trust must not be abused to gain sexual advantage and that sexual relations with clients are prohibited. It also warns practitioners to exercise considerable caution before entering personal or business relationships with former clients. This stance is

common across accrediting organisations. In particular, it is noteworthy that, given the amount of research conducted in the USA, the American Psychological Association (APA) document, Ethical principles of psychologists and code of conduct (2002), states that psychologists should not enter into exploitative relationships, and specifically that they must not have sexual intimacies with current clients, or former clients for at least two years after therapy. There is some debate as to what constitutes a sexual boundary violation. The definition used by the Council for Healthcare Regulatory Excellence (CHRE) report reads sexual boundary violations occur wherever a clinical or therapeutic relationship is turned into a sexual or sexualised encounter (Halter, Brown & Stone, 2007, p. 5). They go on to state that Clinical and therapeutic interventions inevitably render individual patients and clients vulnerable, and trust relies on providing a safe and boundaried space in which these can be carried out without compromising the persons dignity and bodily integrityIt is always the responsibility of the practitioner to manage and maintain these boundaries (Halter et al., 2007, p. 11). Clear boundaries are identified as vital within the therapeutic relationship to help create a safe environment and build a trusting therapeutic relationship. This fits with the aim of making it possible for clients to allow themselves to express or experience problematic feelings, as part of the process of overcoming difficulties (Stiles, Elliott, Llewellyn & Firth, 1990); by so doing, however, the client may become vulnerable or open to potential abuse. We return to the issue of defining sexual boundary violations later in the report.

Research literature The CHRE Review is the most comprehensive and up to date compilation and assessment of the evidence relating to sexual boundary violations, covering empirical literature between 1973 and 2006. It examines reported prevalence and incidence, the impact of sexual boundary violations on clients, and the factors associated with

sexual boundary violations (characteristics of professionals, of clients and situational factors). Its remit is considerably broader than our particular focus in that it includes all health and social care workers and not just those engaged in counselling and psychotherapy. Studies cited are mainly US based but also include research carried out in Australia, Europe and the UK. As acknowledged in the review, the evidence is problematic. Prevalence, for example, is based on a range of sources. More

typically, it is derived from self-reports by individuals through postal surveys targeted at different professional groups; with some groups such as psychiatrists and psychologists being subject of more research interest than others. Response rates vary between a quarter and a half of those surveyed and there is no consistency in the kinds of behaviours asked about. Other sources of prevalence data include: reports from professionals of their knowledge of colleagues sexual involvement with clients; sexual contact with professionals reported by clients; and analysis of complaints or disciplinary action via administrative data held by professional regulatory bodies. Prevalence of sexual boundary violations From the Halter et al review, we find that prevalence rates reported vary with the information sources and the questions posed. The highest prevalence rates derive from studies of professionals acquaintance with colleagues reported to have engaged in sexual boundary violations. On this measure, between a third and a half of professionals were reported as being involved in boundary breaches. It is possible, however that respondents within individual studies may be referring to the same cases. Surveys of professionals asked to disclose whether clients have reported sexual involvement with a previous professional, indicate that around a quarter of clients relate such experiences. Where professionals self-report their own sexual contacts with clients, prevalence rates are considerably lower and have reduced over time. Thus, studies carried out in the 1970s and 1980s offer rates of around 7-10%,

with those for men being two to three times the rate for women; and more recent studies reporting around half the prevalence. Even so it was not always clear

whether different studies referred only to relationships with current clients or included those where the relationship occurred after termination of professional involvement. It is not clear whether the decline in reports of boundary breaches reflects a real reduction or greater awareness of, and perhaps anxiety over, guidelines and sanctions (Halter et al, 2007). Within the UK, a similar prevalence pattern to this international picture was found in the first national survey to be conducted focusing on clinical psychologists who were members of the British Psychological Society (BSP). With over half (58%) of those surveyed responding, 4% admitted sexual involvement with a client, 22% of therapists had treated patients who reported they had been sexually involved with a previous therapist and 38% knew of therapists they suspected of sexual relationships with clients, although only just over half of these had been reported (Garrett, 1998). The existing research literature already suggests that sexual boundary violations with clients by healthcare professionals form a significant component of complaints to regulating bodies, such as the BACP (Khele, Symon & Wheeler, 2008; Gabbard, 1997). In summary, prevalence of sexual boundary violations is difficult to gauge and research efforts in this regard face a number of distorting factors. Whilst survey and questionnaire methodologies aim for representivity, this largely depends on response rates and many of the studies report very low rates. People may be reluctant to participate either because responding may invoke traumatic or conflicting feelings, or because there may be fears of or actual professional and legal consequences. It is clear also, that prevalence rates vary depending on whose perspective is being sought: the possibility of different perspectives on events, associated with vying stakes and interests, can make it extremely difficult to know with certainty what really happened. Structured methods moreover limit the kind of data collected; experiential

components are minimal; the complexity of the individual case is lost; the social processes that contribute to sexual boundary violations, and the contexts in which they occur, are not elucidated. What we can say is that sexual boundary violations comprise a significant problem to be addressed and managed although the size of the problem varies depending on who is making the assessment. Characteristics of perpetrators, victims and situational factors The difficulties in assessing prevalence are carried through into identifying the characteristics of those who engage in boundary breaches. The gendered nature of the problem has emerged from survey data: male therapists are reported as more likely to be perpetrators and women to be victims; although boundary breaches also involve homosexual relationships. A number of studies reported in the Halter et al (2007) review sought to identify personality characteristics that might distinguish those engaged in sexual boundary breaches, with little success in finding characteristics that explain much of the variance (Epstein, Simon and Kay 1992) We sought to explore this further by extending the literature covered by the CHRE report by a systematic research review of recent publications. This addressed the following question: What are the indicators that lead to sexual boundary violations by therapy practitioners (counsellors, psychotherapists and clinical psychologists) in their work with clients?1 It was thus a more specific research question with its focus only on therapy professionals. Four main databases relevant to the issues were searched (PSYCINFO, Web of Science, Medline and Social Care Online) over the period 19972008. Inclusion criteria were: empirical studies; relating to psychological therapists, i.e. counsellors, psychotherapists, and clinical

This review was conducted by Anna Rossiter as part of her course work for a Masters in Psychological Approaches to Health. She was supervised by Anna Madill. We thank her for her contribution to this report.

psychologists2; and sexual boundary violations (SBVs) occurring in practitioners work with clients. Other types of boundary violation, e.g. transgressions between

supervisor and supervisee were not considered. Additionally we sought out reflective literature that might throw light on the question. The search strategy, papers identified and key findings are set out in Appendix 1. With one exception (Moggi et al 2000), all of the empirical papers located were included in the Halter et al. review, suggesting that there is little or no recent research on this aspect of boundary violations. Only six papers were categorised as empirical. Of these, three were concerned with associations between sexual boundary violations (SBVs) and client characteristics, two focussed on the therapists, and one identified a combination of client and therapist characteristics alongside situational factors. Of the six papers, four used a combination of qualitative and quantitative methods, one used only quantitative methods, and one only qualitative methods. Celenza and Hilsenroth (1997) using Rorschach projective technique examined the psychological characteristics of 20 mental health professionals, who had engaged in sexualised dual relationships. The scores obtained were compared to 700 non-patient adults. Overall, scores indicated that the mental health professionals were not grossly impaired but did show acute distress, mostly attributed to situational factors, and some disturbance. The authors concluded that their findings challenged the easy comparison with sociopath repeat offenders, suggesting that this comparison may be overstated on the basis of a few well-publicised cases. Celenza (1998) presents preliminary findings on the characteristics and predisposing factors in 17 therapists engaging in sexual intimacies with patients. 14 men and three women; all male transgressors involved heterosexual transgressions (one or more); and women offenders transgressed in one homosexual relationship. Of
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The review uses the terms practitioners or therapists when referring to these types of health professionals.

these, two sought treatment; two requested supervision following suspension of their licence; one woman sought treatment during her involvement with a patient; two were involved in a patient initiated consultation. Of the remaining ten, five referred

themselves and seven were referred by a professional association. Data were derived from comprehensive clinical evaluations, interviews, psychological tests, consultations with supervisors, colleagues and, where possible, clients. Celenza developed formulations based on the data; many of these were affirmed by the therapists. Therapists described poor early relationships, leaving them with low selfesteem and feelings of neediness and damage or vulnerability. The power relationships in therapy were subverted as the therapist offered self-disclosures, and required the client to respond positively. She noted a theme of damage or wounding, intolerance of feelings of rage and aggression, and restricted use of fantasy; these therapists could not accept that their transgressions were hostile. Those who felt remorse found it difficult to accept their feelings of anger, while those who did not reported conflicts with authority and disclaimed responsibility. Secrets in the family were commonly described; this offered a parallel for the transgression. What seemed most difficult for these therapists was to tolerate the clients view that the therapist was depriving them. Celenza uses Winnicotts model of optimal deprivation to demonstrate her understanding of this important therapeutic role. These therapists felt they could provide something that would make up for and obviate past and current deprivations; what was impossible to tolerate was the clients disappointment and hostility when discovering that therapy and the therapist cannot. In other words, these therapists fall into the trap of thinking that they can offer a corrective therapeutic experience and avoid aggression. She concluded that it was impossible on the basis of these findings to predict therapist sexual misconduct or that the predisposing factors are characteristic of therapists who engage in sexual misconduct as opposed to those that do not.

Somer and Saadon (1999) used questionnaires and a clinical interview to compare results from 27 women involved in therapist-client sex (TCS), with a control group of 26 women. Qualitative analysis revealed a gradual process of boundary violations, often initiated by therapist self-disclosure and seductive behaviour. Eightytwo per cent of clients described TCS as a romantic affair. However, 70% also reported confusion and disorientation. Risk factors within client (younger, female, history of child sexual abuse), and therapist (reputable, middle-aged, male, psychologist, main stream, lone working in independent practice) were described. However, it was noted that this profile fits many therapists and is insufficiently sensitive to distinguish violators from others. In a quantitative study, Moggi et al. (2000) compared female patients (n=57) abused by their psychotherapists to female patient controls (n=43). Questionnaire methods assessed risk factors within personality (self esteem, neuroticism, social functioning), personal background (neurotic style of upbringing, family atmosphere, child molestation) and circumstances at time of psychotherapy (substance abuse, marriage satisfaction, love for therapist). No significant differences were found between groups for most risk factors, but the index group identified more rejection and disapproval from parents and more long-term abusive sexual relationships in adulthood than the control group. Child sexual abuse was common in both index and comparison groups and did not seem to predict sexual involvement with the therapist. Sexual involvement with the therapist was not predictive of reports of mental health at the time of the survey. The authors concluded that client factors did not predict sexual involvement with therapists and suggested that the focus of future research shift to therapist, relationship and process. In another qualitative interview study, Ben-Ari and Somer (2004) investigated the aftermath for women who had engaged in TCS but whose relationship with the therapist had ended two years earlier. Participants were recruited via advertisement.

Of 24 that responded, 14 agreed to be interviewed. Women were aged between 23 and 50 years and with one exception the TCS therapists were men. Research

questions were concerned with the participants views on experiences of self, relationships and their lives in relation to sexual involvement with their therapist. Open-ended questions were used to explore past experiences, focussing on personal characteristics and interpersonal relationships, and present experiences of current self perceptions and views on relationships. Questions aimed to identify why these clients may have become involved in TCS. Participants described poor past and parental relationships prior to the TCS, and low self-esteem. The TCS itself was seen as abusive and harmful, although some still harboured positive or longing feelings for the therapist. Overall, the authors describe a sense of transformation within the sample related to a more positive sense of self. Many had returned to therapy, often with a female therapist, and reported feeling stronger, possibly as they reattributed responsibility for the TCS and previous unsatisfactory relationships. Deciding to participate in the study and resolving the decision to make a complaint or not were significant features of the accounts. Somer and Nachmanil (2005) interviewed 24 participants who reported actual sexual contact with their psychotherapist an average eight years previously, using questionnaires and narratives. Two constructs of the relationship were identified: romantic or abusive, visible in accounts offered in the previous study (Somer and Saadon 1999). The group holding to the romance construct had better emotional well-being at all time points (before, during, and after TCS) than those who construed the relationship as abuse. Both groups reported dependency on the therapist, confusion, and dissociation. In the abuse group, participants thought that therapists focused more on their own needs; whereas in the romance group, emotional wellbeing deteriorated later, after sexual contact ended: all felt exploited and betrayed by the therapist.

In summary, while sexual boundary violations happen only in the minority of cases, these literature reviews support the accepted view that when SBVs occur, they appear to have very serious consequences for the client, the practitioner, and the reputation of the profession. While client vulnerability is associated with higher prevalence, this is not straightforward and it appears to be a combination of complex factors which lead to SBV. Although, some studies have demonstrated common features of offending practitioners, it is also concluded that these are not sufficiently distinctive as to easily identify potential offenders from others.

Serial offender or troubled clinician One issue of interest to professional organisations and regulatory agencies is the nature of the boundary transgression specifically whether transgressions are carried out by a predatory professional or a troubled clinician. One study that sought to address this was carried out by Lamb, Strand, Woodburn and Buchko (1994). Based on a survey of 1000 US psychologists, of whom 327 responded (33% response rate), they found that 6.5% reported being involved in sexual relationships after termination of therapy the majority of them indicating it was only the once (70%), a further fifth on two occasions, and the remaining 10% five times or more. This is similar to the findings reported by Pope, Keith-Spiegel and Tabachnick (1986). This suggests that whilst the serial offender represents a proportion of those engaged in sexual relationships, for the majority this is not the case a conclusion drawn by therapists based on clinical experience of working with those who violate sexual boundaries (Foehl 2005; Norris, Gutheil and Strasburger 2003; Celenza and Gabbard 2003; Gabbard 1997. Celenza and Gabbard (2003), based on respectively the treatment, supervision and evaluation of 48 therapists or analysts (AC) and 150 therapists, analysts and counsellors (GG) who engaged in sexual misconduct, concluded that only around a quarter could be characterised as psychopathic. In a review of a number of disciplinary cases with which he had been involved, Gabbard

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(1997) suggested that practitioners who violate boundaries may have been unaware of some part of their experience, and of the motivations that led them into the sexual boundary violation. He posited that, for some clinicians, the need to maintain positive feelings in the relationship with their clients may have served to avoid the experience of conflict or aggression, either from, or towards the client. It is possible to surmise from this paper and from other accounts (Celenza 1995), that in an attempt to maintain these positive feelings, there was a potentially escalating series of boundary breaches. In other words, whatever the practitioner knows about the existence of boundaries and their value, this knowledge alone is not always sufficient to withstand the experience of anxiety or dissonance. Similarly Norris et al (2003:522), consider that boundary problems are universal concerns and that failure to recognise this can lead to a damaging reluctance to fully examine this topic in every setting didactic, training, consultative and supervisory. This point is reinforced by the findings of Pope et al (1986) that most therapists in their study indicated they had experienced feelings of sexual attraction toward at least one client. One implication to be drawn from Gabbard (1997) is that an experience of personal therapy or counselling might act as a protective factor. Through personal development and increased self-knowledge, the practitioner may be better equipped to reflect on and develop ways of managing themselves constructively in the face of anxiety, pressure or distress. Some training organisations, in particular

psychoanalytic institutes, do require personal therapy with the intention of facilitating personal insight. The evidence for changes, let alone improvements, to practitioner behaviour from personal therapy, however, remains ambiguous (Macran & Shapiro, 1998). There is also a possibility that some experience of personal therapy has been found by therapists to be harmful (Grunebaum, 1986), and a suggestion that there is an increased prevalence of harm in therapist samples over the general population of clients (Buckley, Karasu & Charles, 1981). Equally, there is a debate over the effects

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on practitioners of experiencing distorted or exploitative professional relationships with trainers and supervisors, where, as in clinical practice, there is also a power differential. Anecdotally at least, one of the factors considered significant for unprofessional behaviour in practitioners seems to be the experience of feeling betrayed by one of their trainers, one variant of which is named the analytic virus, a phenomenon considered by Gabbard and Peltz (2001). As it is, there is currently relatively little support in the UK for the requirement for personal therapy to be extended, and some pressure against extending it, so that many practitioners qualify without the experience of being a client. There is some evidence for the positive effect of more active educational strategies. These include the provision of opportunities for practitioners to discuss these issues openly in a non-judgemental setting, and to develop and practise strategies for responding therapeutically to situations in which there is a threat to boundaries. Discussing the impact of attraction to a client may aid the successful management of sexual boundary issues (Halter et al. 2007). The focus on providing such opportunities in training has been relatively recent; many practitioners, especially those who have been qualified for some time, may not have experienced such training and again Halter et al (2007) have evaluated this literature, highlighting the areas of confusion among therapists and students, and the potential for beneficial effects of training on ethical issues and boundary management. Further, there has been a recent emphasis on personal development as an alternative to therapy, with the aim that practitioners might better understand themselves and their experience (Macaskill, 1999; Johns, 2002; Hughes & Youngson, 2008). However, it may be some time before it is possible to evaluate any long term benefits of such strategies. It is also worth noting that Halter et al. (2007) cite findings that suggest that there is a range of opinions expressed by some samples of trainees and students in particular, that would be in conflict with the ethical codes of some regulating

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organisations. For example, in one study on medical students it was reported that, while having sex with a current patient is not considered acceptable; opinions were more mixed when considering such relationships with former patients (Coverdale & Turbott, 1997; cited in Halter et al. 2007). Such differences, and possible deviations from the accepted conventions, are of concern. At the least, it suggests the need for clearer and more effective training. More radically, it might indicate a need to review accepted limits. Given that many, if not all, therapy and counselling training courses include at least some teaching on ethical conduct, it is extremely unlikely that trained practitioners will be entirely unaware of the ethical code to which they must adhere in their practice. Since the development of plans for making accreditation a requirement, practitioners have been required to sign up to codes of ethics, conduct and practice. Accrediting organizations ensure the availability of these, and most send paper copies of such documentation both on first date of accreditation and when these documents are amended. It is unlikely that ignorance is therefore a major factor when practitioners become involved in sexual boundary violations, and it is necessary, therefore, to look for other explanations. In summary, whilst there is some evidence that a number of vulnerability factors implicated in sexual boundary breaches, including professional isolation, earlier experiences of abuse, and personal distress, the most typical pattern is of the troubled clinician who slides down the slippery slope, developing an inappropriate relationship over time. This means that the task of predicting and preventing SBVs may be more complex than previously envisaged. It does, however, offer potential for developing strategies and approaches that might offer success through influencing training, practice, and remediation. Moreover, the albeit limited evidence that most therapists experience sexual attraction to a client at some point even if they do no

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act on it suggests scope for exploring the kinds of strategies employed to manage risk of boundary breaches.

Our study The aims and objectives of the current research were defined as follows: 1. To identify the indicators that lead to sexual boundary violations by healthcare providers who are relevant to the remit of the British Association for Counselling and Psychotherapy; 2. To make detailed recommendations to minimise risk of sexual boundary violations by such healthcare providers. We translated these aims into the following research questions: 1. What do practitioner accounts tell us about the indicators that signal potential or actual sexual boundary violations by counsellors, psychotherapists and clinical psychologists in their work with clients? 2. How do practitioners manage these in their therapy work and what are the effects of such management?

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Chapter 2
Method
This chapter outlines the evolving aims of the research as the team responded to the requirement to recruit a sample of participants who would provide information rich data to answer the research questions. The development of the methodology is also described along with the procedures followed during the study.

Context and research focus This research was designed with the understanding that an accredited practitioner at risk of committing a sexual boundary breach in the United Kingdom will be aware of the ethical dimensions of their feelings and behaviour. It is likely that in these circumstances, he or she may experience conflict over the event itself, about deciding to access support, and in recounting the event, and will attempt to reach a satisfactory resolution of the internal pressures experienced. These may include fears of exposure, shame and punishment. The period of contemplating or initiating the first steps of a sexual boundary violation is likely to arouse anxiety, or at least disquiet. It is, however, through the understanding of these experiences that it may be possible to draw out guidelines for practitioners who face such events. With this in mind, the study was designed to elicit accounts of events that might be seen as precursors of boundary violations in clinicians therapy work. The focus for the study evolved. The team considered several possible strategies. These were interviewing a sample of practitioners who (a) were prepared to talk about actual sexual boundary violations; b) were able to give accounts of therapy work where the strength of feelings of attraction to client(s) resulted in the

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experience of a near miss3; or c) had expertise in the successful management of sexual attraction in therapeutic work. The first was discarded because it was anticipated that there would be ethical issues over recruitment; finding participants who had not been apprehended would be difficult, and it would be unethical given that the clinicians involved with the study adhered to Codes of Ethics which require reporting of colleagues professional misconduct. Also, accounts from those who had experienced an investigation may be shaped by the process and outcome, and would not be representative of practitioners successful management. Similarly, given the range of possible definitions of SBV, recruiting participants to talk about near misses raised ethical issues for those whose description of a near miss constituted an actual boundary violation for the interviewer and team. In addition, we suspected that using this rationale for recruitment might increase the anxieties of potential participants, who might avoid coming forward. Recruitment of an expert sample also posed difficulties; these individuals would need to identify themselves in this way; furthermore, the additional expertise might reduce the sense of uncertainty and lead to accounts that were less typical of the process experienced by those who felt anxious about the possibility of boundary breaches. For these reasons, the final design involved us seeking a typical a sample as possible, including individuals who represented risky and protective demographics. This strategy was also informed by our reading of the literature: if sexual boundary violations need to be considered as more than the province of a few that have nothing in common with the rest of us (Gabbard 1995:1116), focus on the strategies therapists employed in their day to day practice to manage experiences of sexual attraction, would offer a way of examining therapists vulnerabilities in the therapeutic environment.

A near miss is defined as an event or situation that could have resulted in undesirable consequences, such as an accident or injury (in this case a SBV) but did not, whether avoided through chance or deliberate action.

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Choice of research methods Quantitative methods, even questionnaires, seemed inappropriate for the research aims and would have required lengthy and impractical qualitative components to collect data that would have been of sufficient value to offer guidance to the profession. Moreover, there has been increasing interest in using qualitative methods in counselling and clinical settings. Qualitative methods allow an analysis that captures complexity and nuances of participants experience and the meaning they place on events as they give their accounts. Although it is not possible to generalise extensively from a small sample, in depth qualitative research findings may extend understanding of other research studies and provide useful support for practical recommendations. The frameworks and principles arising from such studies may guide understanding and identify future areas for exploration. Hence, there were several advantages to adopting a qualitative research strategy for this studys focus on practitioners experiences of managing the risk of sexual boundary violations. A qualitative research approach would: (1) Provide accounts of practitioners views and beliefs in relation to vulnerability to breaching sexual boundaries, and the management of potential sexual boundary violations; (2) Allow practitioners to offer a complex narrative enabling an analysis of the key moments of conflict and choice; (3) Allow researchers to use their reaction to the participants and to their stories to inform a deeper human understanding of their struggles; (4) Encourage detailed discussion of the practitioners definitions, values and strategies for management of events involving sexual attraction, including the use of external and internal supports and resources.

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It might have been possible to offer answers to these questions through a number of study designs. The eventual decision was to use a qualitative design, in which a sample of practitioners were interviewed and asked to provide accounts of their views on sexual boundaries and their experience of negotiating these with sufficient success that the practitioner managed to avoid sexual boundary violations.

Reflexivity: Reviewing the research teams understanding The research team consisted of four core members, all female academics from different, albeit related, disciplines. Two have clinical components to their posts and are accredited as practitioners. All have experience with qualitative research methods. All team members also have an interest and previous involvement in research into the practice, process, and outcomes of counselling and therapy, and therapists experience. Three have experience of ethics committees for either clinical or research issues. The composition of the team brought several advantages, with a variety of positions and research strategies. In particular, the combination of clinical and academic members allowed some confidence that the clinicians were not limiting the analysis through their assumptions about the nature of clinical work, while they added depth and relevance to the analysis of clinical material, the clinicians themselves worked with different frameworks which made it possible to avoid the uncritical adoption of one model of psychological work. As in all qualitative research, the way in which the data is understood by the researchers requires explanation. This is perhaps especially necessary when the data is participant narrative rather than direct observation and the content of the interview is likely to be emotionally complex and anxiety-laden. In this study in particular, the researchers were aware of the potential for accounts to be shaped by the anxieties of the participants and, in particular, anxieties about the judgements of others. The team recognised that these might include fears of being seen as

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incompetent, concern over being perceived as acting inappropriately, or even to be considered as having acted in a way that merited reporting and investigation. Moreover, participants might feel a wish to elicit reassurance or recognition. Such concerns would be likely to lead to inconsistencies, inarticulacy, or moments of tension in the accounts. We were also aware that the interviewer, or imagined readers of the research report, might stand in for judgemental others, including registering bodies and condemning colleagues, or even the possibility that participants might experience interviewers as external versions of internal critics (Hollway & Jefferson, 2000; Kvale, 1999; Martin, 2001). The methods of data collection and analysis needed to be able to take these into account. Additionally, it was decided not to interview practitioners who had broken a sexual boundary in the course of their work (with clients, students, or supervisees etc.). The reasons for this were twofold. First, the discussion of actual transgressions poses ethical challenges beyond the scope of this research. Second, we were aware that the consequences of breaching a sexual boundary, and of any subsequent investigation, could lead to a change in the practitioners expressed views due to the need for self-protection. Given the above consideration, in order to fulfil our research aims and research questions, the specific objectives that evolved were to: (1) Recruit and interview 12-15 relevant healthcare providers (counsellors, psychotherapists, clinical psychologists) who identified themselves as having experience of sexual attraction between client and practitioner, and of having managed this in ways that did not result in a sexual boundary violation with a client; (2) Analyse these interviews using a thematic qualitative methodology in order to explore:

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(a) Practitioner definitions and characteristics of appropriate maintenance of boundaries, of their understanding of what would constitute a sexual boundary violation within the context of their work with clients; (b) Views on whose responsibility it is to maintain boundaries; (c) Views on reporting violations and near misses, including the role of clinical supervision; (d) Reflection on, through detailed descriptions of practice examples, the factors giving rise to the temptation to commit a sexual boundary violation and how such temptations are managed successfully; (e) Knowledge of, and attitudes to, available guidance on managing sexual boundaries with clients and the use of this information, and; (f) Experiences of training aimed at promoting ethical practice. With the development of qualitative approaches that can recognise the ways in which an account may be shaped, and which include systematically the experience of the researcher in analysing the data, there is potential for a clearer understanding of the experience of these dilemmas and problems and therefore for developing frameworks and recommendations. The methods developed for use in this research aimed, therefore, to maximise the depth and sensitivity of our study through incorporating researcher reflexivity throughout the processes of data collection and analysis. This was operationalised, for example, through interviewer debrief meetings so that the researchers reactions to talking with participants could be used to develop insight into the topic of practitioners experiences of managing the risk of sexual boundary violations.

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Ethical issues A number of ethical issues were discussed in relation to this study. Given the sensitivity of the topic there were concerns over the storage and disposal of data, anonymity of participants, the potential for previous or on-going professional or social relationships between some interviewers and some interviewees, and the disclosure of previously unreported sexual boundary violations. Solutions to the issues were adopted as follows: the study developed information sheets describing the study and consent forms (appendix 2&3); interview data was digitally recorded and deleted from the recorder after being stored on the main university server only (a secure, password protected site). Written materials were stored in locked filling cabinets, and identifying data were kept separate from interview transcripts and audio recordings. Transcribers signed a confidentiality agreement and were given guidance on conventions for anonymising transcripts. Transcripts were titled with a code number for interviewer and participant, e.g. I2 P3. Both auditory and textual data will be archived within LIHS for seven years as required by the University of Leeds and destroyed after that point. It was agreed that no participant would be interviewed by an interviewer with whom there was a previous or current relationship and that, where such a relationship existed, the data would not be analysed by that researcher. In particular, the use of accredited clinicians as interviewers potentially placed both researcher and participant in difficult ethical positions, especially where there might be differing views on what constituted a boundary violation between therapy modalities. As researchers, we felt we had a duty of care to participants. There is also a duty of care to clients and accredited clinicians agree to abide by Codes of Ethics and Practice that include statements to the effect that they will not condone and will

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report potential misconduct4. Hence, an important issue was the need not to invite confessions of misconduct. In order to protect potential participants, it was agreed to make explicit statements, both in the written materials and during the interview, at the start and at any point that the interviewer became concerned that the participant might be disclosing a previously unreported sexual boundary violation that the interviewer felt would be likely to require reporting. These were to the effect that the aim of the research study was not to collect accounts of actual sexual boundary violations and the interviewer would not seek accounts of these. Additionally, the interviewer would warn the participant if (s)he became concerned that such a disclosure might be made; that if there were a sexual boundary violation described, the interviewer might be obliged to report it to the participants professional organisation for investigation, and that if this was the case, the interviewer would inform the participant that (s)he would discuss the event with the research team and let the participant know the outcome. If it were decided that the breach required reporting, the participant would be given time to make the report themselves, if that was wished. In the event, there were no accounts within the data set amounting to misconduct of a degree of severity that the team considered the need to report any participant. The study was reviewed and supported by the Ethics Committee of the Leeds Institute of Health Sciences, University of Leeds (appendix 6).

Sampling strategy Our sampling strategy was developed to reflect ethical and theoretical considerations. Our initial thoughts were to recruit practitioners who would define themselves as having experienced a near miss in relation to a sexual boundary violation with a client, as they would might be able to offer a rich and detailed account. The potential

Two of the four interviewers were accredited clinicians, through the BPS and UKCP.

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variation in practitioners definitions of the difference between a near miss as opposed to a breach, however, again left the team aware of the conflict between the need to protect participants and the obligation to report misconduct. For this reason, we were explicit that participants had to declare that they had not committed a sexual boundary violation, whether investigated or not. This meant also that the agreed focus for the interviews was on experience of, or expertise in, managing potential threats of sexual breaches to therapeutic boundaries. Practitioners who have experience of managing such events without becoming involved in a sexual boundary breach were thought to be, potentially, particularly information rich for the proposed research. In contrast to those who have actually violated a sexual boundary, we considered that they would be more prepared to be interviewed, more open about their experience, and less motivated to produce a deliberately distorted or selfprotective account given that they managed to avoid a breach of guidelines and of their code of ethics. Participants would, however, have been exposed to the same struggles, to similar circumstances, and would potentially have developed strategies, more or less constructive, to cope with their dilemmas. There seemed to be no straightforward way to recruit participants who were expert at negotiating sexual boundary events in therapy. Asking practitioners to identify themselves as skilled and experienced in these areas, we recognised, would bring forward those with the confidence to self-define in this way but leave us unable to attract a range of practitioners who might be more tentative about their abilities. So, without observations, the researchers could not assume a direct correlation between self-definition and expertise. Our solution was to draw our sample from experienced and practising practitioners that were currently accredited with one or more of the following organisations: the British Association of Counselling and Psychotherapy, the British Psychological Society, the United Kingdom Council for Psychotherapy, the British Psychoanalytic Council or the Association for Dance

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Movement Psychotherapy UK5. This excluded those still in training or not currently accredited. Further, given the potential impact of gender and age on vulnerability to sexual boundary violations, we sought to include a mix of male and female participants within different age groups. Finally, for pragmatic reasons, in particular the time constraints on the study, we decided not to recruit participants via the National Health Service (NHS) but to only recruit therapists via other routes and whose main clinical work was conducted outside the NHS. 6. In summary, the sampling strategy was theoretically and purposively driven. Following a number of interviews, a secondary sampling approach was devised to ensure inclusion of participants of different sexual orientations.

Recruitment We decided to recruit through several routes in order to maximise the potential for a range of participants and accounts, and to increase the variation in the motivation for participation. This would increase the likelihood that the findings might resonate with the body of practitioners. Two main strategies were employed. First, several methods were harnessed for disseminating information about the study and attracting potential participants. These included an initial report and a notice in Therapy Today; a notice in The Psychologist; a page on the University of Leeds website was developed with an email link, and emails distributed through local and national organisations and email

This was chosen in order to broaden our sample to include therapists practising outside of the verbal therapies in which the body is a central vehicle for the work. 6 This criterion was included for two reasons: first, the practical one of avoiding the need to secure NHS ethical approval, multiple site R&D approval, and honorary NHS contracts for non-NHS researchers, which would have meant a delay to the study deadlines; and second because there is a suggestion that independent practice may be a risk factor.

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networks. Second, to extend recruitment, four participants were identified through personal and professional contacts. The source of recruitment and characteristics of the participants are outlined in Chapter 3. One pilot interview was included, so that

the final sample comprised thirteen practitioners.

Data collection Participants were interviewed using a semi-structured format. An interview protocol was developed which interviewers used flexibly and as a guide to increase coverage of the main topic areas (appendix 5). The interviewers aim was to offer the initiative as far as was possible to the participant, to use the guide to map identified areas for exploration, and to use consistent and recommended phrasings in questions and prompts. The participant was free to develop their own account in the way that made most sense to them while the interviewer followed-up unanticipated, relevant directions of enquiry if introduced by the participant. The interview schedule was developed in a number of stages. Given the sensitivity of the issues involved, two of the team (CM and BM) consulted a panel of clinicians with extensive experience of counselling, therapy, and training. A focus group methodology was used for this. The focus group members commented on the proposal, on interviewing and a draft of the topic guide. This group meeting was audio-recorded and a transcript made of the feedback from the panel members for use in developing the study. A revised version of the topic guide was developed and two pilot interviews were carried out with a volunteer who fitted the inclusion and exclusion criteria. Participants were interviewed by any member of the team who was able to offer an interview, and the only criterion employed was that participants were assured an interviewer who was unknown to him or her. Given the potential for anxiety arising from the interview focus, and the possibility that some participants might feel more

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comfortable talking with a male interviewer, arrangements were made for this eventuality. Advertising material offered this option and one participant did request this, so that a fifth interviewer was brought in to conduct the interview (GN). He was prepared for, and supported through, the process by one of the team members. Immediately after each interview, interviewers made notes of their experience. They then met another member of the team as soon as possible for a debriefing meeting, which was digitally recorded and transcribed. This allowed the interviewer to reflect on the experience in the presence of another; and initial reflections captured and refined through discussion. In two cases, where there was no auditory record, and the interviewer took more extended notes7, the recording of the debriefing meeting served as an opportunity to extend the record of the interview itself as well as to provide additional information on the interview experience. Transcription conventions are included in appendix 7.

Data analysis The analytic process was initially conceptualised as a focussed thematic analysis, drawing on Miles and Huberman (1994) and Braun and Clarke (2000), but the methodology evolved in response to the challenges of the data. Given the teams awareness of the sensitivity of the topic and the potential for emotionally-laden material and for anxiety, it was agreed that we would ensure that the analysis would take account of the interviewers experience and make best use of the varied academic and clinical expertise of the team. The transcripts were therefore worked on by two of the team. Each pair consisted of an academic and a clinician, in order to challenge commonly held assumptions made by clinicians, and to ensure a clinical reading of each transcript. To assist these steps, we used Free Association Narrative

In one case, the participant asked for the interview to be recorded as co-constructed notes which were agreed after discussion at a second meeting. In the other, the digital recorder failed. The interviewer attempted in both cases to make notes as close to verbatim as possible.

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(FAN) principles as developed by Hollway and Jefferson (2000). FAN draws on psychoanalytic theory in requiring the analyst to pay attention to the significance of possible reluctance, anxieties, changes of linguistic structure and topic, and sequences of text as indicative of the complex processes involved in constructing the account. There were therefore a number of stages of data analysis, outlined below. Stage 1: Transcripts of the participant interviews were first checked by the interviewer, who corrected errors and added initial comments. The debrief interviews were listened to and reflective memos developed. Stage 2: Participant responses to the questions on attitudes and beliefs were identified. Stage 3: Each transcript was allocated to a second member of the team. An initial thematic analysis was carried out by the interviewer and a second team member. Following this, the pair met for development of the analysis and to reach consensus on the themes identified, to consider additional themes as well as to elaborate on and refine their dimensions during several meetings. All of the data, including notes and records of the debriefing meetings were available for this phase. Memos were constructed during this process, outlining issues arising from the discussion and commentaries on the development of the themes. A marked copy of the transcript was developed which identified the sources of the agreed themes. Stage 4: Accounts of clinical experiences of attraction were identified and themes arising from these examples were considered in relation to each other across the sample. From these, key processes, experiences, and choice points were identified. These were incorporated into diagrammatic form reflecting the core process being described by participants. An analysis of problematic experiences led to the emergence of themes which were developed into a typology.

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Stage 5: Accounts of experiences in supervision were collated and analysed separately. Again, key themes were identified and a model developed describing the process through which supervisees worked as they used supervision to manage their experience with the client.

Quality checks as part of the analytic process As can be seen in the above description of analytic procedures, the team instituted several checks of the analytic process for a number of purposes. Each transcript was checked by the interviewer against the original recording for accuracy; the team members read all transcripts, unless this would breach an assurance of confidentiality; analysis was conducted in stages with discussion at several points. Team meetings were used to discuss the analysis as it progressed and themes were shared across the team members so that developments from one pair influenced other analyses.

Contextualising the findings: Secondary literature reviews During and after the analysis, the team pursued further relevant literature. In particular, a body of reflective literature (as opposed to empirical reports) provided a source of clinical experience and expertise which could be considered practice-based evidence. A total of thirteen papers were identified and sourced, some from the review conducted by Anna Rossiter, then reviewed and tabulated. Themes were then identified from the reflective literature by two team members, who refined these into the form offered in the concluding chapter.

Reporting conventions In offering data from the interviews, the prime considerations were to provide a flavour of the participants views and experiences. To this end, short verbatim extracts have been selected for inclusion, and accounts of events have been

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described. Given the relatively small community of practitioners, and the detail provided on their work practices, we reached the decision to include these without specifying from which interview each was taken. Extracts are either indented between paragraphs in the text or at times are included as part of the text. In both formats, they are italicised. Extracts have been amended to be grammatically correct and repetitions and hesitations removed unless their absence significantly changed the meaning of the extract. Given the small sample, it was decided that extracts and accounts would be kept brief and presented with the minimum of identifying contextual material. References to gender of participants and others, to age, sexual orientation, working environment, or other characteristics have been avoided, unless the absence of such information is essential for making sense of the account. At points, the exact number of participants offering a theme or having a particular characteristic is specified. At other times, there is an indication of proportion. This reflects the teams preference for managing uncertainty; for example, there were topics that some participants did not raise or were left implicit in the accounts. Rather than assume that only those participants who explicitly discussed a theme held this to be important, we have used terms such as a few, several, some, the majority, many and most, and the order given is that intended to be taken by the reader.

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Chapter 3
Participants Characteristics, Motivation for Participation and Attitudes to Boundary Issues
This chapter outlines the characteristics of the participants in the sample, including recruitment source, indicates the motivations offered for agreeing to take part, and explicates the views expressed during the interview.

Demographics The sample was made up of seven men and six women (table 3.1). This balance was deemed to adequately cover the over-representation of male transgressors in studies concerned with identifying characteristics of offenders. The age range was weighted towards older participants, which has the advantage of allowing the collection of accounts from an experienced, potentially expert, practitioner group. It also means that accounts of the high risk middle aged male practitioner is represented within the data set. Although the majority of participants worked independently, there were several who had been, or were currently, in public sector employment, including the NHS, and some of those described as in public sector employment had previously worked independently. The sample was sourced through several routes. Four contacted team members after having seen advertisements in professional journals; four responded to emails sent out via local networks, and four were recruited directly because they increased the heterogeneity of the sample. The final participant was recruited for piloting the interview. In terms of profession, several had more than one training or definition. The largest single group were seven counsellors, all BACP accredited. Three identified

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themselves as psychoanalysts or psychoanalytic psychotherapists; one of these was also one of the two clinical psychologists. Two were accredited as Dance Movement Psychotherapists, and one counsellor also worked as a life coach. The thirteen identified the therapeutic approach they felt reflected their primary model. Seven preferred psychoanalytic or psychodynamic models. Three described themselves as integrative, one as relational, one as systemic, and one used cognitive-behavioural concepts. All thirteen offered individual therapy. Two participants also worked with couples, two with families and three with groups. Two noted specifically that they offered counselling to adolescents. Eight of the participants spoke of experiences of personal therapy. Three were clear about never having undertaken therapy for themselves, and two did not speak of personal therapy at all. All thirteen had experienced regular supervision arrangements through most of their work as therapists, and all but two were currently in such an arrangement. The two practitioners who were not in supervision at the time of interview were recently retired. Two had group supervision, eight individual supervision (one or more supervisors) and two used peer group supervision (one practitioner had both a group and individual supervision).

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Table 3.1: Description of participants Identifier Sex Age (yrs) 50-59 Employment Registering Bodies BPS/UKCP Qualifications Therapy modalities Individual Supervision Type Length (yrs) Peer 5

Frequency Fortnightly

I1

P1

Public sector

P2 P3 P4 I2 P1 P2 P3 I3 P1 P2 P3 I4 P1 P2 I5 P1

M F M F F M M M F M F M

60+ 50-59 60+ 30-39 40-49 60-69 50-59 40-49 30-39 60+ 50-59 40-49

Selfemployed Selfemployed Selfemployed Public sector Public sector Selfemployed Selfemployed Selfemployed Selfemployed Selfemployed Selfemployed Selfemployed

BPS BCP BACP/AFT ADMP UK ADMP UK BACP BACP BACP BACP

Clinical Psychology/ Psychotherapy Clinical Psychology Psychotherapy Counselling

Individual, couple Individual, adult Individual, family Individual Peer group Individual Group Individual Individual Individual Individual, group Individual Individual

22 16 21+ 2 9 20+

Previously weekly none currently. Weekly None currently 3 weekly Weekly Monthly

Dance Movement Individual, group Psychotherapy Dance Movement Individual, group Psychotherapy Counselling Individual Counselling Counselling Counselling Psychotherapy Individual Individual Individual Individual, family Individual, group Individual, couple

Fortnightly Fortnightly

20+ 20+ 11

Weekly 2 different supervisors monthly Monthly

BACP UKCP

Counselling Counselling

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The participants expressed a variety of reasons for taking part in the study. The two most common reasons offered were; an interest in the role of sexuality in therapeutic work (six mentioned the importance for their work in particular, or for therapy in general) and interest in ethical issues (three had been involved in the ethical processes of accrediting organisations). A further theme can be best construed as altruism. Some were aware of having to learn to manage clinical situations where sexual boundaries became a cause for anxiety or concern, in less than ideal circumstances. Concerns were expressed about client well-being and, in particular, the desire to ensure that these issues might be better understood in the service of the clients development. Several had found the presence and affective potency of sexually charged components of therapy challenging, and even surprising, and felt that these issues had been inadequately explored during training. Many had felt unsupported and there was a strong sense from several participants, that they had offered themselves in the hope that their experiences would contribute to changes in training and professional activities so that future cohorts of practitioners would not have the same struggles. Some found that their engagement with certain client groups or areas of work raised sexual boundary issues frequently or strongly and, therefore, felt they had developed expertise through experience, which it might be helpful to share.

Practitioner views on boundaries and boundary keeping The unanimous view of participants was that for a practitioner to engage in a sexual relationship with a client is wrong, and terms such as intolerable were used to describe this. There were, however, differing views toward lesser boundary crossings which were expressed in relation to a number of other types of breach. Touch was considered a breach by some practitioners while it was seen as a valid component of the work, at times at least, by others.

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I dont physically touch the client but I will habitually shake hands as part of normal human contact. Never reach out and touch a client who is distressed its wrong to play on a clients vulnerability. Two participants described a transition in their practice from one view to the other; both developed stronger prohibitions on touch or other non-verbal behaviours following experiences with clients who misinterpreted gestures. One also described a decision to avoid touching clients after feeling intruded upon by the touch of a supervisor. For example, one participant described an incident that led him to change his stance when he put his arm around a distressed client and felt her resistance: There was a feeling then that it was a token of being the warm empathic counsellor to hold your client. I barely used touch again because of that. Of note is the fact that the two Dance and Movement therapists adopted strategies for managing and minimising touch: I use a lot of work with props so theres sort of the more touching through props and the sharing and exchanging of communication that way. However, one participant pointed out that physical touch was the mode of greeting in his culture of origin and that it was not given the same meaning among English friends and acquaintances, who had challenged his taken for granted behaviour both generally and in therapeutic encounters. Other behaviours, such as flirtation, and apparently minor breaches such as lapses in keeping to time, were viewed as potential precursors to more substantial breaches. Meeting outside the therapy setting, even for apparently therapeutic reasons, was considered risky. For some, there was concern over self-disclosure. Views varied on when and how self-

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disclosure was acceptable, or even desirable, but the general principle underlying decisions was client benefit. All participants also held the view that it is the practitioners responsibility to maintain boundaries. Those participants who discussed supervision experiences also considered that sexual relationships with supervisees were unacceptable. One participant also found the conduct of colleagues who initiated affairs with each other as problematic. All participants recommended the use of supervision for understanding and managing threats to the boundaries of therapy. Most were able to describe experiences of using supervision to discuss attraction to clients, or for other types of clinical issue involving sexual feelings or material, or when there was a threat to a sexual boundary. Such discussions were not uniformly experienced as positive and this is discussed in more depth in Chapter 6. One issue raised by several participants was the uncertainty they felt over reporting their concerns about the conduct of colleagues and clients who were practitioners. There was lack of clarity over the type of evidence needed to make a complaint about a colleagues conduct, with the anxieties that it might be considered gossip or malice. Moreover, there were concerns about potential conflicts between reporting misconduct and maintaining confidentially should a practitioner reveal breaching sexual boundaries in their personal therapy (the requirement to report being seen as meaning the loss of an opportunity for the practitioner to learn to work within accepted boundaries). Such situations placed participants in anxious and conflicted positions, concerned over harm to clients, practitioner, and self. Supervisors were the usual source of guidance, and their advice was taken seriously, even when this left the practitioner with a degree of unease. Several participants noted that they viewed other specific behaviours in relation to clients as boundary breaches. These included accepting gifts, seeing the client socially, developing the therapy into a friendship, dating and initiating email contact. This extended

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for many to the possibility of relationships with past clients. Only one participant thought that successful post-therapy intimate relationships might be a possibility, and then only some time after termination. Others questioned whether the differences intrinsic to the therapy relationship could ever be overcome, with some particularly concerned with the inequality in power between practitioner and client. Some felt that the need to overcome this power difference when developing a personal relationship would be problematic regardless of other considerations, and several commented on the difficulty in developing a more mutual relationship for both individuals. Eight participants made statements to the effect that sexuality was universal and was therefore a normal, and even usual or predictable, component of the therapy experience. But its okay to have difficult feelingsyou cant pretend that sexuality isnt part of therapy. Sexuality is ubiquitous. However, sexual fantasy proved a problematic area for boundary breaches. Several participants categorised sexual fantasies about clients as a potential boundary breach, one of these thinking that while one could not avoid passing fantasies, the deliberate use of such experiences for ones own satisfaction constituted an abuse. One participant was prepared to accept such fantasies and thought that they were harmless, while yet another felt that it was a matter of the persistence and location (outside sessions) of fantasies which were indicative of a breach. On the other hand, several participants considered that fantasy was a source of information and that the practitioners task was to understand what it might mean for the therapeutic situation, so that it could be used to the clients therapeutic benefit; one participant talked of dreams about clients in the same way. One of the defining principles for most participants was that their actions should be carried out for the clients benefit, and not their own, and this arose at times when discussing fantasy, perhaps .precisely because it would be easy to argue that it would do the client no harm.

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There was also a theme of sexual boundary breaches and their management as forming continua. The first continuum was defined as early and small boundary breaches which needed to be understood in order to work therapeutically and to avoid more major boundary difficulties. Management of this varied, with some responding to such issues by explicitly restating the boundaries they worked to, and others providing more empathic interpretations. One participant commented that lesser breaches than sexual relationships are incorporated into codes of ethics and practice, and that practitioners need supervisors and colleagues to note these early breaches and work with them over these, without having to be taken through a punitive disciplinary process. A further theme was the recognition that sexual feelings may be understood as part of the difficulties the client brings because s/he struggles with this area of living. To respond to these difficulties and behaviours with a sexual response denies the client the opportunity to understand and change, denies them the chance to have therapy. The wrong side is sexualising the relationship. Its appropriate to explore sexuality but not to sexualise the relationship. There is a healthy use of sexuality it goes with the territory its not about sexualising the relationship or even wanting to sexualise the relationship. Along with the Scylla of the sexual boundary breach was the Charybdis of other reactions. These included the recognition that the practitioners anxiety might lead to a rejecting or punitive response, or avoidance of the issue: .but there is also a middle category not working well sexuality is not spoken about and is put in a box. Feeling you want to push the client away because you cannot deal with it. I will protect myself professionally even when it leaves the client feeling very distressed.

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Many participants recounted examples of work with clients when anxieties and uncertainty combined, with the result that the practitioner behaved in a way that avoided a sexual boundary breach, but which were felt to have had negative effects for the client. These were often appended by comments indicating that the practitioner regretted the way they had felt impelled to behave then, and they reflected that with the experience they had accrued during their work, they would handle these events differently, and hopefully, more constructively.

Practitioners views of available ethical codes guidelines for ethical practice Views on the available guidance varied. Few referred routinely to the documents. Some held that their training and the ethical documents offered by their accrediting organisations were of little help in real-world practice. Others found the training they had experienced on the values and use of the ethical frameworks to which they were committing invaluable. Some of the variability could be attributed to the time since practitioners completed training. One possible interpretation from these accounts is that those who had been trained relatively recently had received more, and better, training on ethics and, subsequently, a more positive experience of this aspect of their studies. Regardless of time since training, however, there was a strong sense from some participants that the guidelines, while worthy, did not help the practitioner manage the complexities of the clinical situation with its conflicting demands and competing ethical dimensions. Alongside the conflicts with which practitioners struggled, there came recognition of a need to balance benefits and harms in relation to a number of stakeholders, and decisions were made harder by uncertainty as to procedures and outcome. Some practitioners felt a need for ethical guidelines to be written in terms of principles that would facilitate the balance of potentially conflicting interests, as is already the case for some, e.g. the BACP Ethical Framework. Several held the view that the practitioner needed to develop internal ethical principles which would serve as a guide, and this was understood eventually by the research

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team as describing a process analogous to the development of an internal supervisor (Casement, 1985). There was also a view, expressed by some, that the ethical guidelines were intrinsic and integral to the work and that therapy would be compromised and limited, or even that therapy would not take place, without adhering firmly to the boundaries. In other words, these participants felt that the practitioners attention to boundaries, and their capacity to keep them secure, enabled the client to feel safe and provided the opportunity to experience and learn from the therapeutic space, with its inevitable frustrations and reassurances.

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Chapter 4
The Therapy Work: Managing Risk
In this chapter, we draw out from participants accounts the processes involved in containing therapeutic boundaries. Sarkar (2004) defines a boundary in professional practice as the distinction between professional and personal identity, the purpose of which is to keep both safe. It is, he argues, a metaphorical term for the construction and limits of professional identity, indicating not only the difference between personal and professional roles but also the structural differences that characterise the interpersonal encounters between professional and client. From a psychotherapeutic perspective, Gabbard (1997) suggests that the concept of the therapeutic frame allows the therapist to be empathetic and warm, while it simultaneously creates a sense of safety for the patient (p. 323). Three issues are important to note at the outset. First, whilst our particular focus in this study was management of risk of sexual boundary violations, many of our participants, although acknowledging the significance and ubiquity of sexuality and the erotic in therapy work, made the point that sexual feelings are not the only emotions that may be stirred up between therapist and client. Other kinds of emotional responses anger, irritation, fear, dislike can be evoked in therapy with potential for destructive and constructive impact on clients and also required work on the part of the therapist to manage for client benefit. Second, as we describe in more detail later, clients may use sexuality or overt sexually charged behaviour as a way of avoiding or masking relationship difficulties or problems of intimacy more generally. Third, the therapeutic encounter was seen by most participants as imbued with risk in the sense that engaging and understanding the other means that one is open and available to the other, and therefore vulnerable to having ones own emotions stirred. Understanding and managing intimacy was therefore viewed as part of the territory that therapists have to negotiate routinely. Therapists are not separate from the clients they

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treat. They are both the objects of clients feelings and subjects of feelings themselves evoked through their encounters with clients.

Intimacy and distance (or engagement and separation) Most participants, from different theoretical frames of reference reflected that understanding and managing emotional depth necessary to engage with clients requires that the therapist simultaneously seeks to manage intimacy and distance. Metaphors used by participants of the process included: Getting into and more significantly getting out of the mud; Working at the edge; Negotiating through murky waters; Feeling uncomfortable it goes with the territory. Some of the metaphors employed by participants, for example, working at the edge have a particular meaning in some disciplinary frameworks. Other participants drew on such terms as transference and counter-transference from psychoanalysis to indicate role and relational confusion in the therapeutic context that requires understanding and management. Youve got to be there with them and detached enough to think about whats going on at the same timeyoure not a detached observerif you dont do the two, youre not doing the job properlyyou have to get close to someoneyou have to allow your feelings to get affectedwe should be open or available enough to be stirred upso that we are affectedits not that were detached in a way that they cannot affect us were not only scientists with them in that sense but there has to be the scientist feel, like the analyst, there at the same time. The essence is that the therapist is a participant in the sense of engaging with the client intensely, as well as being an observer of the clients behaviour, thinking about what it means, reflecting on what is aroused in oneself, and working through how these are played out in therapy.

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The common element of the processes described is the therapist as simultaneously participant and observer, as separate and engaged. We use the term participant/observer drawn from ethnography as a way of creating a shared language that is not unique to a particular therapeutic framework, albeit it is informed by clinical experience. Participants, drawing on specific examples from their own clinical experience, considered that assuming the role of observer only or creating excessive emotional distance is as problematic as is engaging as participant only or over-involvement. Indeed, the work of therapy, it is argued, involves an ongoing struggle to sustain and manage the tension between the observer/participant dynamic. Such a struggle is not only located within the therapist, it is also becomes part of the work with the client. One participant, talking of supervising practitioners, said: If I dont get to hear about any of that struggle [Im concerned} that theyre not aware of that potential intimacy or getting confusedsexuality and boundaries can pop up and be broken in all kinds of relationships so if the murky waters arent ever brought up [in supervision] then there is something not being thought about either in the clients world which is being projected onto the therapist and things that arent being processed In the context of managing the observer/participant relationship in therapy however, sexuality and sexual feelings present particular difficulties. They can be difficult for the therapist to talk about openly, treated as taboo or abnormal, giving rise to anxiety about seeking support and guidance to deal with them in supervision. Some participants thought that clients may sometimes become confused about the intimacy and closeness of therapy, unable to separate out the therapeutic relationship from real relationships outside therapy and fantasise about the therapist as girlfriend or partner. Sexualised language, gestures or overtures by clients may evoke anxiety in therapist such that they take fright rather than stay [with the client] and think about what it means for [him/her]. This effect appeared

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across the accounts given by our sample, and was as apparent in independent practice as in specialised therapy contexts such as single gender residential settings. In this sense, whilst the erotic and sexuality are seen as generally present in any therapeutic encounter, they pose particular difficulties of positive management in therapy because of the taboos surrounding them. In the following pages, we describe the components of the therapy process that we have constructed from participants accounts of their practice with clients in managing sexual or other intense emotional content in the therapy encounter. Two points are worthy of note. First, each and every element of the process set out here appeared essential toward managing emotional depth, including sexuality, in therapy. Second, our conception of this process has been developed both through exploration of concrete examples provided by therapists with different clients with whom they had worked more or less successfully and their reflections on strategies they had adopted n the face of difficult clinical situations. Figure 4.1 describes the individual components as: noting; facing up to it personally; reflecting; processing; formulating; and using the understanding therapeutically for the benefit of the client. Box 4.1 provides a worked example. . It will be evident that guidance and support via supervision may be sought at any point or indeed at several points in the process.

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Figure 4.1: The process of managing intense emotional content in therapy Engagement in therapeutic work and experience of relationship with client Noting Anxiety/ disquiet/ uncertainty Facing up to it personally: that there is an issue to be understood Reactions e.g. curiosity, shame Reflecting

Processing: Struggle to reach understanding and working through

Developing a therapeutic meaning for these real feelings/ symbolic thinking Owning a formulation: naming the situation

Accepting situation without undue selfblame- curiosity

Relief, Insight Disengagement from feeling Feeling more prepared/ armed Working with/ doing differently for therapeutic benefit

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Box 4.1: An example of the process Using anxiety about boundary breaches to develop an intervention Younger female participant, working with male clients with a forensic history in residential settings. Clients often miss relationships with women and tend to see their therapist in the context of these absent and perhaps problematic relationships, so that the therapy stirs up strong feelings in both the men and their female therapist. The participant identified dilemmas over how to deal with these feelings in session as a continuing area for development. Noting is a routine component of therapeutic sessions in these contacts. Problematic dimensions of the relationship become apparent in sessions, through feelings of attraction, feeling attacked, or unease, giving rise to tension and awkwardness. The practitioner may feel uncertain about the way to manage these in the here and now, feeling unsure about the clients reaction to discussing the issue, and anxious about acting without thought, in case an intervention has unintended consequences. This requires her to make a decisionwhether to act within the session or whether to stay silent about the experience and take the feelings to supervision. The participant reported using supervision to question; why are you acting as you are, what it means for the client, and this means putting a name on it. This helps working on the issue with the client. There is sometimes an additional area for thought in supervision - these situations may generate feelings related to the past and current relationships of the therapist. Key features Noting: The client asked her if her gestures meant she fancied him, whilst at the same time he was resisting therapy work and it felt hard to work with him. There was a sense of sexual tension; his questions felt provocative and scary Facing up to: This meant recognising the presence of tension in herself and realising that these feelings were linked to elements of her personal life, and with experiences of past and current relationship situations Reflection: She reached an understanding that the client was acting and she was responding in order to mask another emotional situation that both found more painful or difficult to tolerate Processing: In reflecting on the clients situation and internal conflict, and separating out what her own vulnerability and person contributed to the tension (observing self as well as other) separately from the clients contribution, she was able to start to manage her own response and refocus her emotions on her own life experiences Formulating: This led to developing a model for understanding the role or function of shaping up this situation in therapy for the client - in this example, she felt he was avoiding dependence on another, who might act badly towards him if he were in her power Using therapeutically: This facilitated her in making links between his need for relationships and the difficulties he experienced with them (deprivations, frustrations and anxieties). One key intervention was an interpretation that the qualities he was seeing in her, were qualities he liked to see in a partner. This intervention broke the sense of sexual tension. This discussion went on over a number of sessions, however, before it for the client.

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Noting Noting is triggered by a heightened anxiety or sense of threat or an awareness of the clients appearance, stance, or behaviour. What is going on here? Why do I find myself reacting more strongly than is usual for me? Why am I being affected? Why do I feel threatened in some way about what the client has said; how s/he presents him/herself? What is this communication about? How do I understand whats happening so that I can work with it for the clients benefit? Noting relates to feelings evoked in the therapist that may not be entirely sexual, but may be feelings for clients that were perhaps beyond the normal empathy or warmth Noting is about the feelings evoked in the therapist, and also the sense of confusion and uncertainty being in two-minds about what is going on that requires reflection and consideration. It is both about what is going on with the therapist and what is being communicated by the client. I put the pause button on and think about this as a communication from the clientI tell my internal supervisor that this needs to go to supervisionto help me understand whats going on Im in the murky waters suddenlyand I need to pause and reflect and take it back out of the session. This noting is a first step toward bringing to the fore, to face up to, what is going on. In a sense, facing up requires normalising these experiences and emotions as not being shameful in themselves. Some immediate processing may take place within the session. Typically, it is likely also to be identified and reflected on as something that needs to be taken to supervision. you get warning signs into your response where you think suddenly ah this is a little bitand I feel a bit too warm towards this personthat happens socially as well as in professional practice. And so I suppose I tend to put the

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brakes on very strongly or to compartmentaliseyou just split off the bitjust a self warning and just watching my own responses and the checking out of interventions I might make Noting requires sensitivity to the client, self awareness on the therapists part, and a sense that this is something that needs to be picked up and examined: I took it to supervision part of it was a response to the clients stance and use of sexual attraction in her relationships generallyunderstanding it more made it possible to get to a more contained experience. There are particular work contexts in which overt sexual advances may be made by clients, as in single sex residential environments: I might be sitting at the start of the session and it could be just somethingif I bit my lip not realising that Id done that, he would say: does that mean that you really fancy meso that sparked something in myself that kind of feels unsafeI need a lot of guidance in how to work with him because the sessions hes really difficult to work with hes very negative and its very hard for him to take on help because hes always got something to push back that would automatically be something about his erotic fantasiesso that is quite difficult for me. Participants made a distinction between feeling sexually attracted to a client and finding the client attractive in the sense of being likable which meant that work with such clients was experienced as particularly enjoyable. Yet, such situations also required antenna sensitive to noting, in part because of the danger of holding on to clients when therapy had come to a natural end. Id watch the imageryone of the tests would be if one was becoming too socially engaged without elevating therapeutic discourse to a special plane

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which is differentits when you realise that youre talking to a clientas if with friendsthat tellsthat the work has come to a close or reached a point where theres not much more to do and thats the point to stop.

Facing up to it personally Facing up to it is linked with noting; it nevertheless involves a further stage of reflection as in: This is something I have to deal with; this needs to be brought to the fore and worked through. Practitioners may decide to refrain from acting on their thoughts or feelings in the session, and may store their experience for later examination and reflection outside the session. It may also be taken to supervision to consider how it can be worked through. Sexual relations can be played out within session material but theres that boundary of whether you act on it and how you dissect the information and use it appropriately if you feel that thats something that can be brought up within the session theres that real sense of nervous tensionthat can be awkward that Ive experiencedso if theres a place where I can look at them with them then I willI found it useful with the supervision to help me come back to thatIm unsure of how to handle it in appropriate ways so sometimes [in the session] you sort of pretty it up and try to push it back a bit because you dont know how to look at it Personally facing up to it may involve both an immediate internal response and a compartmentalising of aspects of a response pending further discussion and reflection in supervision. On occasion it can be dealt with in the session. One participant recounted how much earlier in their career, a client had indicated at their first session a desire to have sexual intercourse with the therapist. Whilst feeling personally threatened and internally reflecting that this was a clear no-go area, the therapist did not immediately respond, considering that the client had come with relationship issues of which this was a

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manifestation and to explicitly reject the client would have been non-therapeutic. Instead, it was taken to supervision to continue the process of reflection and formulation.

Reflecting This is the process of separating out the meaning and significance for the therapist and for the client, of what generated the heightened anxiety in the therapist: I want to look at it the right way and not make them (clients in group work context) feel scared or awkward or bad for having those kinds of feelings its important that I understand why those feelings are evoked in me, whether that could be something to do with my past, my own relationshipand why I might be feeling something toward someone in the group or why they might be feeling something toward me. Reflecting is about pulling apart, separating out and naming what is going on for both therapist and client. It implies self-reflexivity self awareness and knowledge on the one hand, and a level of honesty and integrity to name what is going on, on the other. It also requires being able to go beyond self to focus on the client. Reflecting and naming may take several sessions to achieve. It takes conscious effort on the part of the therapist since it involves facing up to what can be difficult areas of experience. with the one person and that also made me think about maybe I see qualities [in the client]that actually I like in my own relationshipsI dont think you really think about that For therapists as well, the feelings generated in them may relate to their sense of being responsible for the progress that was achieved. There was something about being able to see that progressthat part of me that felt like a proud mother.

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Reflecting is distinguishable from processing which is the next phase.

Processing Processing involves working through possible solutions that will be beneficial to the client. This is where knowledge and skill comes into the equation: how to work through the meaning and implications of the feelings generated in the encounter for the therapy work. Being able to work through this in supervision was seen as helpful and indeed a necessary part of the process on the assumption that the supervisor would be open to explore such tricky issues. One client [in the group] I was very aware ofwhat is it that hes stirring up in methere were feelings on his side that we looked atqualities they say in me that they would like in their own girlfriendsin their own relationshipswe looked at - because you could feel this kind of sexual tension within the group but no-one was willing to put a name on itI went to supervision and discussed it Part of the processing may include awareness of contexts in which the therapist may feel particularly vulnerable, positive or negative. These may include experiences or events in the practitioners own life, for example, the strength they derive from their own relationships, their degree of comfort in their sexuality or, conversely, difficulties in their personal relationships at that point in time. I recognise that I need to take care and monitor situations when I am not personally in a relationship: it is not appropriate for me to try to meet my emotional or physical needs for contact through my client work. I try to meet my emotional and tactile needs through a network of friends. The reality of my life is that sometimes there may be days or even weeks when I have very little contact with my friends; clients cannot be a substitute for these relationships,

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this connectedness, and there are times when I must actively re-establish intimate connections with those closest to me, acknowledging that these may be times of emotional vulnerability. There may be vulnerabilities relating to the work context, as for example, female therapists working with male offenders in an all-male environment. Inexperienced therapists may respond to anxieties by erecting rigid boundaries. Reflecting, particularly with a supportive and supervisor seemed to enable the practitioners to learn and develop confidence in mastering the participant/observer stance.

Formulating Building on processing is formulating and developing strategies for use in relation to the client. and then I went back to the group and it was the same kind of atmosphere (sexual tension) and I was able to put a name on it andI think some of the qualities you see in me are some of the qualities that actually youd like in your own relationshipsthere was this sense of relief that this sexual tension had been brokenand thats really hard to do An aspect of formulation involves thinking how to contain sexual feelings whilst working therapeutically with the client. For example, how does the therapist respond to a client who acts in a flirtatious manner whilst not damaging the relationship? One participant described how one client would flirt in therapy. Over time and through engaging in the processes described above, the practitioner came to understand the flirtation as an attempt to manage status, uncertainty and control in the sessions, and began to use this formulation to explore the clients concerns and anxieties in a manner that was neither confrontational nor rejecting.

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Working for therapeutic benefit This may include strategies to both stretch boundaries and retain/reinforce bounded areas but the focus is on how to use the understanding therapeutically for the benefit of the client. Using the understanding therapeutically for the client may mean that the therapist chooses the opportunity to pose tricky issues when it seems most appropriate for the client. The processes of reflecting, processing, formulating then using the understanding therapeutically for the client were seen as the way the best work was done, i.e. practitioner emotions were not acted upon without awareness, but were used in the development strategies for therapeutic benefit. This is the space that participants described variously as murky waters or the edge spaces that were scary but at the same time where the therapist was most sensitive to what was going on with the other person whilst also self consciously aware of their own actions and reactions. A common theme from participants was that therapeutic boundaries those that defined the therapy space such as time, place and nature of the relationship - were important factors in enabling them to manage the intensity of the therapeutic work, containing it within this environment.

Summary In this chapter, we have examined the nature of the therapeutic encounter and the processes involved that facilitate management of risk of sexual boundary violations. The process model was created through analysis of what seemed to work positively for therapists and clients. It represents an ideal in that therapists also viewed the process as one in which they were engaging in an ongoing struggle. In the next chapter we examine some of the specific examples recounted by therapists where they experienced particular difficulties and the lessons drawn from them.

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Chapter 5
Problematic Strategies and Creating Safe Boundaries
In this chapter, focusing on specific examples from practice, we explore what were perceived as problematic responses to the management of sexual boundaries, either by the participant or another, such as supervisor or the research team. We then consider those professional and organisational boundaries found helpful by therapists in containing the therapeutic space.

Sexuality as ubiquitous in therapy As we have discussed in previous chapters, most practitioners viewed sexuality as a universal feature of the therapy experience one component of the difficult emotions that arise in therapy. Clients sexual overtures, while evoking uncertainty in the therapist, can also offer clues to deeper problems in relationships that they find difficult to communicate and master. Responding appropriately requires staying with the client, not running away thereby allowing the therapist to think about what this meant for the individual... By not responding defensively and by naming the behaviour openly, the therapist provides a boundary stabiliser within which underlying issues around loss and commitment can be explored and worked with. Further, practitioners also recounted instances where they experienced sexual attraction to clients. Key however was not acting on it, not sexualising the therapy relationship or even wanting to sexualise the relationship- this was seen as abuse of the client. These views echo findings from research elsewhere. Thus, Pope, Keith-Speigel and Tabachnick (1986) found that the majority of practitioners responding to a survey indicated that they had at some point been sexually attracted to their clients. The professional literature emphasises that practitioners need to be able to differentiate between sexual

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attraction, which is inevitable, and sexual acting out, which is unethical and destructive (Thoreson, Shaughnessy and Frazier (1995:88). Even so, the ubiquity of sexuality in therapy did not mean that it was easy to manage attraction appropriately and for client benefit, as the complexity of the process described in Chapter 4 attests.

Sexuality: Problematic responses Alongside accounts of successful management of sexual boundaries in therapy situations, some participants also described events, sometimes from early in their careers, when they had handled individual situations in ways they felt they would not wish to repeat, and from which they had learned. Others recounted recent events that, while avoiding a reportable boundary violation, had results that were considered problematic or unsatisfactory in some way, whether to the participant or the research team. We have characterised these problematic responses into four main types: self-protective/defensive; moralising/omnipotent; neediness; and over-protective anxiety. In different ways, these stem from therapists inability to manage in the moment the simultaneous participant/observer stance.

Self-protective/defensive Practitioners offered case examples of situations in which fear or anxiety relating to possible therapeutic boundary breaches led to them reacting in an unthinking, defensive and sometimes punitive manner without anticipating the impact on the client. In the first example, the practitioner, who was attracted to the client, deflected overtures to meet socially by reinforcing therapeutic boundaries this is therapy and were here to work for your benefitand theres no point coming otherwise. The client never returned and discontinued therapy.. The practitioner felt in retrospect that this defensive response related to lack of experience and ability to work with the attraction, being a newly qualified therapist. Now, with experience the focus would be on:

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thinking how to use this therapeuticallyto understand the transference and counter-transference and link it back to issues in the persons life and use the material to help them think about what theyre doing in their life outside. A second example concerned a practitioner working with a couple, then with each individually for a number of sessions after the relationship broke down. Some weeks after therapy ended, the client waited outside the therapists workplace after normal working hours and approached the therapist, who was leaving, suggesting that they might meet socially. I [therapist] made my excuses and leftI feel more ashamed of this now, that I did get the manager to send a letter warning the client offI was just afraid of my own reactions and wanted to put some kind of sure line downI felt too threatenednow I perhaps would have suggested we talk about it in a session perhaps The sense of guilt and shame expressed by therapists reflecting on self-protective action reinforced their view that it represented poor practice in not fully taking into account the impact of their behaviour on clients. Participants also provided examples to indicate how clients were adversely affected by self-protective action on the therapists part. One specific account here referred to a client who had experienced long-term, severe and enduring mental health problems and came with additional marital problems. In one of their therapy sessions, the client declared love for the therapist. The therapist reacted with surprise, responding to this as indicating a real attachment; conveyed to the client that this was impossible and the therapy ended. The organisation offered the client another therapist; this was declined and the client subsequently experienced a mental health crisis in which fantasies relating to the therapist featured. The therapist perceived that their failure to appropriately manage the relationship was a factor in the clients relapse. Protective/defensive responses may also reflect practitioners fears about being pushed into areas that they personally find very uncomfortable, and where it may be easier

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to think: Im going to finish with this person because Im not doing them any goodbut really its because Im finding it too painful, I cant cope with it. Several points are worth noting here: first, these kinds of encounter were not unique to either male or female therapists; further, they occurred across mixed gender encounters female therapist/male client and male therapist/female client as well as same sex encounters that involved gay and heterosexual therapists. Second, defensive and self-protective responses were considered problematic and arising out of either lack of skills or experience, or unreflective acting on heightened anxiety and fear. Third, self protection on the part of the therapist could have adverse, destructive consequences for the client a conclusion that is also drawn out from the professional literature, based on practice experience (Gabbard 1997; Grunebaum 1986). Thus, Gabbard (1997:323) argues: Maintaining excessive emotional distance from the patient can be a form of counter-transference rigidity masquerading as ethical adherence to

professional boundaries. In such cases, therapists may conduct themselves in this rigid manner with a conscious intent of reassuring themselves that they are beyond reproach in an ethical sense. The unconscious intent may be to drive away the patient, which is often the end result. We found that self-protective action did not define the general stance of most participants, i.e. they indicated they had learned from their experiences to reflect on their own response and would formulate and act differently now. A self-protective/defensive action and stance does however indicate an inability to manage the duality of the participant/observer relationship in this particular moment of a therapy encounter. Here, instead of engaging with the client, the therapist symbolically pushes the client away. Further, in the context of sexualised behaviour or sexual overtures on the part of clients, selfprotective action is illustrative of how the taboos and fears in this area lead to rejection of the client, whilst ostensibly protecting the therapist professionally. Thus:

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there comes a point with these sexual boundaries and intimacy boundaries where the imperative is to protect oneself professionallyeven if it leaves the patient very, very distressed thats not very good for the patient but it protects me. Yet, it was acknowledged that when sexuality is not spoken about and is put in a box, therapy cannot work well.

Moralising/omnipotent Another type of problematic response in managing boundaries is what we term moralising or omnipotent. As with the protective/defensive response, this also flows from the therapist failing to manage difficult situations, then taking a stance that increases separateness and distancing themselves from the client. One example here draws attention to the tension between establishing boundaries to create a safe therapeutic space and adopting a rigid approach in controlling what can be explored within that space. Here, the practitioner talked about an experience with a client described as very lonely and needy. Considering that the client was seeking a degree of intimacy that was considered inappropriate, the response was to state loudly and explicitly that therapy was not the place to be comforted or for socialising. Here it was not the reinforcement of the therapy boundary in itself that was seen as problematic but in the way it closed off exploration of the clients neediness. An additional element of this, and of the previous strategy, may be the adoption of the position of expert, as if by putting the client in the wrong, the therapist can relieve themselves of anxieties about incompetence or guilt.

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Neediness/over-identification Participants emphasised the significance of self-understanding and of being grounded in their own personal relationships as crucial for maintaining the observer/participant stance. Some, at particular points in their lives or where they were experiencing relationship difficulties or losses, provided accounts of over-identification with the clients difficulties based on their own neediness that posed a risk of problematic responses to managing boundaries, both in terms of the quality of engagement or of managing intimacy and sexuality.. In this example, the participant described emotional turmoil evoked in respect of a client whose child had died; this was subsequently assessed by the therapist as being a boundary breach in terms of over-identification, if not explicit feelings of sexual attraction. It happened in a session that was scheduled for 50 minutes but which lasted about two hoursI was so encumbered by the awfulness of itI identified much too closely and much too intimately with this parents experience because this was one of my most profound fears At the time, the therapist indicated that it was the client that brought it to attention saying that: You look shocked, horrified and pale, that if you cant bear to hear what Im saying, Im going to stop coming because I feel what I bring to you hurts you too much to hear it. It is of interest here that formal boundaries marking out the therapeutic space as for instance the timing of sessions help to create a safe place within which therapists can engage appropriately with the duality of intimacy and distance/ participant and observer. What might appear simply as organisational constraints that at times can be seen as

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arbitrary or even inhumane, in fact help to sustain the therapy encounter as a specific form of contact whose purpose is to be of benefit to the client. In another example, the therapist described being very attracted to a client and felt this was mutual. Whilst this was not discussed nor acknowledged and therapy continued to what was evaluated as a positive negotiated ending, the experience gave rise to questioning about whether such emotional responses should be discussed overtly with clients and whether such openness could have been therapeutically useful. Although the therapist did not act on the feelings of attraction, this was felt to be a difficult experience, resulting in having to bear feelings of longing and anguish over a period of time, and at the time of the interview still wondered whether the feelings were based on real compatibility. This issue is also linked with different interpretations of the professional role in some therapeutic approaches, for example person-centred therapy (see for example, the discussion in Gabriel, 2005). Whilst some person-centred therapists consider the possibility of an expanded therapist role beyond the traditional therapy hour (Thorne, 1987), Gabriel (2005:32-33) suggests that intimacy between client and therapist is a complex and potentially problematic area of therapeutic relating and drawing on Holmes (2001), she notes that the paradox of intimacy is that we can only achieve it if we can negotiate separateness successfully. Those with difficulty in separating out from a significant relationship may find intimacy hard to achieve.

Over-protective anxiety Some participants reflected that on occasion, they had unthinkingly responded to the clients anxiety in a way that subsequently made them question whether their actions might be construed as straying across the appropriate therapy boundary in order to provide care that was later seen as possibly inappropriate, or was anxiety-driven. One example was when the therapist gave their personal telephone number to a client with the explicit purpose of offering reassurance over a break. In retrospect I think it might have been better not

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towhether

you

would

call

it

boundary

breachbut

it

was

probably

mistakesometimes you do these things and you dont know whether theyre right or not. Another example was drawn from a participant as supervisor who challenged a supervisee on the use of their mobile phone for engaging in text conversations with clients outside of the therapy time. For the supervisor, this was viewed as indicative of lax boundaries, and a matter of concern. Touch was cited as one of the demonstrations of overprotective care. One participant spoke of the conflict experienced when a client moved to embrace her; she described the impulse to reject the hug, alongside an anxiety that the client would feel personally rejected. She opted for a compromise she felt was unsatisfactory, allowing the client to hug, but putting her hand on the clients shoulder to limit it and in what she felt was a maternal fashion in order to prevent it being mistaken for anything other than innocent. In summary, problematic responses to sexuality and intimacy issues in therapy can be viewed as different ways in which the struggle for the dual participant/observer stance is not achieved. On these occasions, either the therapist acts on the basis of feelings or assumptions, without reflection, or alternatively thinks, but in a detached way, perhaps without concern for the clients state. Being pulled in either direction either toward the detached observer or participant stance means that one ceases looking at self in relation to the client for the purpose of benefit to the client. Whereas self protective and moralising strategies remove the therapist from considering what is happening with the client, resulting in detachment; overinvolvement means that the therapist in becoming engulfed in their own emotions and needs, and similarly loses sight of the clients emotions. Anxiety, lack of knowledge and experience, and personal characteristics, including one's history and perspective on the world, may adversely affect understanding of a challenge to boundaries. The result is one of

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these less desirable reactions, through incapacity to think through the meaning and implications of actions. The relationship between these problematic reactions and strategies and the process followed by practitioners as demonstrated in Figure 4.1 in the previous chapter has been developed into an amended process as illustrated in Figure 5.1 below. The problematic reactions disrupt the process of working through the meaning of boundary breaches or feelings in relation to boundaries and clients. The list of reactions identified has been drawn from participants accounts, but is unlikely to be exhaustive. What was clear, however, was the recognition that although each problematic strategy disrupted the process, reflection, either alone or through discussion with another, e.g. in supervision, might make it possible to move on from the strategy; with an understanding of the significance of the reaction, the practitioner could resume working through the process.

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Figure 5.1: Problematic responses to intense emotional content in therapy Engagement in therapeutic work and experience of relationship with client

Losing the balance between participation and observation Noting Anxiety/ disquiet/ uncertainty

Avoiding, denial misunderstanding

or

Facing up to it personally: that there is an issue to be understood Reactions e.g. curiosity, shame Reflecting Denial, irritation, pathologising the client, infantilising, or infatuation

Processing: Accepting situation without undue selfblame- curiosity Struggle to reach understanding and working through

Developing a therapeutic meaning for these real feelings/ symbolic thinking

Blaming, over-protective, becoming the expert/ authority, considering feelings are real

Owning a formulation: naming the situation Relief, Insight Disengagement from feeling Feeling more prepared/ armed Working with/ doing differently for therapeutic benefit Seeing the feelings as generated by the clients problems, experiencing the relationship as real

Acting on the feelings in punitive, over-protective, seductive, demanding, exploitative or paternalistic ways

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Chapter 6
Supervision
This chapter covers the functions and experience of supervision as described by the participants. Given that there was a sense that participants offered supervision as the primary, and first, source of support for developing constructive responses to potential threats to therapeutic boundaries, the area seemed to merit specific exploration.

Supervision, professional context and training Supervision was seen to take place within a professional context, which included the work environment, colleagues, employer and professional community. The expectations on a practitioner to undertake supervision were seen as crucial, and there were observations that some organisations did not require or ensure that supervision was available or took place. Colleagues and links with a professional community were viewed as a potentially important influence, for good (but occasionally poor) practice, and isolation was identified as a risk. It was recognised by some participants that supervision skills themselves require training and reflection. Several suggested that supervision needed to be included in training, and that supervision of supervision is valuable, or indeed essential.

The functions supervision is seen to serve In their accounts, participants treated supervision as a support for learning in the face of anxiety and uncertainty, and that the capacity of the supervisor to contain anxiety was in itself an aid to learning. The process usually described was a sequence of discussion of the case, reflection on feelings, behaviours and concerns, and new understanding, often followed by resolution (at least to some degree) of uncomfortable emotions, sometimes advice, and a return, hopefully better armed, to the therapy situation. There was a theme around supervision being fit for purpose: some participants noted the challenges of the

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possible range in personal styles of supervisor and practitioner, and the effects each working with different models, and of the necessity of allowing sufficient time to move beyond discussion of techniques. The core aims for supervision held by participants were therapeutic benefit for clients and the development of therapist skills, but there was a strong sense that supervision was a professional standard in itself and a means of upholding professional standards. One participant described the need for supervision as as important as insurance, or having a proper consulting room necessary to do the job properly. Another stated that regular supervision and contact with the professional community should be part of codes of ethics. Several participants commented on the need for the supervisors approach to fit with that of the therapist. This did not seem to require that the two use identical models. However, some participants considered that where there was a lack of congruence between the approach adopted by supervisor and therapist in regard to what was deemed an appropriate ethical stance, it made it harder to manage problematic situations. This might include for example, differences of opinion over boundary issues, such as use of touch. . Supervisors were seen as more knowledgeable and their advice on ethical issues taken seriously. While the majority of the participant accounts suggested that supervisor responses were experienced as understanding and thoughtful, two participants described examples of taking concerns about reporting issues to their supervisor from early in their careers. These accounts illustrated two different and problematic responses. One participant was concerned about a clients professional conduct. When this was discussed in supervision, the supervisor had advised that the boundary breach being described needed to be managed therapeutically rather than through reporting, so that the participant struggled over the issues with the client for some time. It seemed to the interviewer that in this instance, the practitioner was still left with questions. A second participant felt that the concerns he had outlined about a colleagues professional conduct to his supervisor were taken by the supervisor as indications of his personal pathology.

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Participants expressed the view that supervisors have a role in maintaining ethical standards. Four participants felt that they have responsibility to look for issues around sexuality and need to be aware of potential indicators of risk, staying alert to potential risks and to small breaches. In particular, the supervisor might note any signs of the practitioners self esteem being overly dependent on clients improvement, or any sense that the therapist might feel special. Contracting was seen as important to good supervision and protective for situations where sexual boundaries were discussed. Given that sexual breaches are only one type, it was felt by some participants that the issue might be proactively included in contracting in relation to general boundaries. Making the roles and professional responsibilities of each participant explicit at the start was seen as beneficial. This included discussion of the possible actions required of the supervisor should there be any particular concern about the practitioners professional conduct. It was seen as positive that supervisors might discuss the ubiquity of sexual feelings during contracting and then continue to take the position that discussing issues around boundaries and sexual material forms a routine part of supervision. Once contracted for, then in discussions of clinical material, the supervisor might beneficially question the practitioner on the presence, extent and nature of sexually related material, such as fantasies about clients. A further area of concern to participants was the way the supervisor handled situations where personal material of the therapist was relevant to the discussion of the client material. While it seemed important that supervisors allow practitioners to make links between personal issues and their involvement in the therapy work, and that the skills to enable practitioners to talk about embarrassing personal material was important, participants felt that the supervisor needed to keep a boundary between supervision and personal therapy, and encourage the use of personal therapy when this seemed appropriate or helpful. One participant felt that a supervisor had encouraged more self-revelation than felt comfortable, and found the experience unhelpful for the therapy work.

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Some participants noted that supervisor and practitioner might have been trained in different models of therapy, and that some boundaries might have different meanings. There was a concern that this might at times be difficult for the practitioner receiving supervision. A particularly invidious combination was the practitioner with more liberal boundaries than the supervisor. One participant compared experiences with two supervisors, one psychoanalytic, who was experienced as punitive and pathologising. The other, from a humanistic background, was experienced as understanding and accepting or normalising. This situation made the interviewer aware of the risks for practitioners inherent in working with two supervisors. The feelings of rejection attributed to one and the approbation of the other might, in some circumstances, limit the value of the supervision offered by both.

Supervisory tasks: Managing the setting of supervision Participants expressed clearly what they felt was required of supervisors in relation to both the supervision setting and supervisee, and to the clinical work brought by therapists. These included attention to boundaries in supervision itself as well as in clinical work, and there were references to supervision as a safe setting, enabling the practitioner to clarify what was expected. Practitioners valued clear and explicit boundaries. One valued boundary was the confidentiality offered by the supervisor. The supervision setting was seen as a space to talk honestly about uncomfortable material, including accounts which might give rise to embarrassment or shame, those that showed how the practitioner might be struggling and perhaps reluctant to discuss their plight, and those where there had been a little slippage. All these were viewed as essential areas for supervision, in order to avoid bigger errors or breaches. Supervision was seen as a place for truth, and for talking over issues that it might not be beneficial to make public or note down, whether for client or practitioner. It was recognised that practitioners might need different responses from the supervisor depending on their level of experience. Some might feel unprepared for managing sexual boundary threats early on, and might need more practical guidance at this point.

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In order to make most use of this aspect of supervision, it was felt that the supervisor needed to be able to facilitate openness and honesty. Both contracting and the supervisors response to difficult material were considered important. This need for a safe environment, in which the therapist can feel confident that their disclosure will not shock the supervisor nor fear attracting judgements for admitting to sexual fantasies, is also found in the literature (Ladany, 2005; Twemlow, 1997). One valued characteristic was a supervisors capacity to remain calm (rather than become anxious) and therefore able to explore. Interested inquiry both acted to assure the practitioner that this was an appropriate supervisory task, and facilitated exploration and honest self-evaluation by the supervisee. The supervisor might participate in discussions on the effect of personal issues on the work, role misunderstandings and difficulties including abuse (sometimes these were framed as transference and counter-transference), and feelings that felt incongruous to the practitioner (such as disgust or love). Nearly half of the sample emphasised the importance of avoiding a punitive response, even while recognising the need to, at times, ask difficult questions. These might require the practitioner to reflect on the effect of their internal dynamics might be involved in supervision as well as in the clinical situation. Three participants spoke of a parallel process, one expression of which might at times be a feeling of sexual charge within the supervision session that might repay reflection. This needed sensitive exploration. After discussions which were managed well, however, some participants reported that the tension resolved and sexual feelings within supervision and therapy with the client, dissipated. It was noted that supervisors are only human. One participants account included an example in which their personal issues around sexuality were seen to have played a part in the supervision. Another expressed disappointment that a supervisor had seemed embarrassed when there was a moment of sexual tension, and reported it as a lost opportunity to learn something helpful for the therapy work. These accounts resonate with the recommendation that supervisors need to understand interpersonal dynamics, including those elements that might be drawn from past experience (transference and

countertransference) (Gabbard, 1997: Garrett, 1998).

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Supervisory tasks: The activity of supervision The primary task of the supervisor, however, was seen as joint meaning-making. Successful supervisors were seen as holding complexities in mind. For example, they took into account the two relationships (therapy and supervision) and would attend to issues in both as appropriate. At times, this might involve making links between the two. At other times the focus would be on one. One participant described the way a supervisor would remain aware of the different experiences of both the therapist and their client, balancing these and taking both into account. In this way, they assisted the therapists understanding of an anxiety-provoking situation, with the aim of reducing the practitioners anxiety and capacity to respond without thought or an impulse to self-protection. This might involve monitoring the engagement and reactions of the supervisee. One tension inherent in the task was between normalising and problematising experiences in relation to threats to therapeutic boundaries. In terms of sexual aspects of the work under discussion, it was expected that the supervisor would be in a position to notice and initiate a discussion when concerned. This might mean making sense of small cues, such as a feeling that the practitioner is not bringing their experience of sessions for supervision, a sense of pressure in the work, perhaps to be special or to make a success of the case, and then bringing them into the discussion, naming what seemed to be unsaid. The next stage involved developing the therapists understanding that their feelings of attraction may have some meaning for the issues the client brings to therapy, often symbolic, and that understanding their own response might facilitate better understanding of the relationship with the client and the function of the feelings for the therapy encounter. A further task for supervisors to undertake was to help the practitioner to develop a stance or even guidelines for future sessions, which would limit or remediate boundary breaches, and make it more possible for the therapist to regain their therapeutic equilibrium. It was noted by some that this is important when the client has experienced difficult past

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experiences with similarities to those occurring in the sessions, that the supervisor help the therapist consider whether and how their activity in the session might repeat or sustain the clients experience of abuse.

The supervisees role and responsibilities The final area mentioned by participants was the supervisee. It was felt that the primary responsibility for the client work lay with the therapist. The supervisor was facilitative, and was not always in a position to know of breaches without being informed, even when there might be cues that were suggestive. Gabbard (1997) also commented on the problem of supervisees keeping secrets from supervisors. It was therefore for the therapist to be as open and honest as possible about their work, and to include their difficulties and reactions, the therapy relationship and their own engagement in the work, and small breaches in spite of discomfort. Once these had been disclosed, it was the supervisees responsibility to explore these. A key concept, mentioned by four participants, and implicit in the accounts of others, was the internal supervisor (Casement, 1985). A distinction was made by one participant between a healthy internal supervisor and one that might be harsh and judgemental or one that was experienced as sitting on my shoulder. The supervisees task included nurturing the development of their own internal supervisor. As the practitioner developed, understanding of their experience increased, and then informed future practice. This allowed the therapist to note what might need to be taken to supervision, e.g. noticing anxiety about a session, a feeling or a response; and also facilitated reflection and making links, e.g. between issues described at assessment and the development of role relationships during the course of therapy. When the therapist felt under pressure, the healthy and experienced internal supervisor would be mindful of the possibility of acting out and how destructive it could be, facilitating the adoption of options and means of managing oneself in sessions.

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An interesting development of this concept seems to be the recognition, sometimes implicit, of an internal ethical committee. Several participants seemed to have made a distinction between the therapeutic elements of their activity and the ethical, recognising that if their therapy skills failed them, at least they could return to their ethical stance and moral code. One participant described this as an internal No. While this is clearly an important issue in training, there remains an element of this that cannot be controlled for; the capacity to internalise and manage ethical standards seems to develop over time. One participant described the guidelines as offering a safety harness. Later, the capacity to use the boundaries therapeutically develops from this initial reliance on the guidelines.

A model for working in supervision Figure 6.1 shows a model for working in supervision that arose out of our higher order conceptualisation of the material described above. It is possible to see here a reference to the place in which the murky waters are stirred up: the area of discomfort and struggle. This place is in the overlap between what is in full awareness and comfortably known, and what is underneath or at the edge of awareness, and defended against. Our participants variously described this as the edge, the mud, and various other evocative terms. The degree to which supervisee and supervisor are able to work within this area is determined first and foremost by the level to which the supervisee is able to feel safe within the relationship. However, systemic factors can either impinge or support, as can the

supervisees development of her or his internal supervisor.

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Figure 6.1: A model for working in supervision

Systemic factors + -

Supervisor brings issues into awareness

The Murky depths

Issues remain hidden in the depths

+ Internal supervisor / monitor

Summary In this chapter, we have considered the supervisory relationship, and note the high expectations of supervision as an activity. There are several roles outlined for supervisors. Clinically, these comprise a focus on client benefit, management of the supervisory relationship and contracting, facilitating the development of the practitioners capacities for understanding and working therapeutically, and with theory-practice links. These form a mirror image to the practitioners own roles, and there are potential contributions supervisors might make to support and develop therapist work at any point in the process model described in Chapter 4. In addition, the supervisor is seen as providing a quality check, by monitoring the therapists accounts and their own experience so that threats of boundary breaches might be brought into discussion, however difficult it might be for the therapist, with the intention that violations might be avoided or at least remedied through reporting.

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Chapter 7
Summary, Conclusions and Practice Implications
This chapter includes a summary of the key findings, followed by a discussion of the implications for practice, including recommendations derived from the research. There is a section outlining the strengths and limitations of the study, with reference to future research areas. Finally the chapter ends with general conclusions.

Research questions and summary of the findings This study sought answers to two research questions, namely: 1. What do practitioner accounts tell us about the indicators that signal potential or actual sexual boundary violations by practitioners in their work with clients? 2. How do practitioners manage these in their therapy work and what are the effects of such management? The findings range across a number of areas relevant to clinical practice. In Chapter 4, we drew out from participants accounts the processes involved in containing therapeutic boundaries and developed a model created through analysis of what seemed to work positively for therapists and clients. This model articulates the following process: (1) noting; (2) facing up to it personally; (3) reflecting; (4) processing; (5) formulating; (6) working for therapeutic benefit. The model represents an ideal in that therapists also viewed their capacity to work through threats to boundaries as demanding. When threats to boundaries occurred, these were experienced as a struggle that might be extended over several, or even many, sessions. Participants felt that successful outcomes for their work with such situations resulted in increased understanding of the clients difficulties and often therapeutic benefit. The concept of the participant/observer, taken from research contexts, provided a model for making sense of the participants experiences of both engaging with the client and

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participating in the experience of the session, on the one hand, and , on the other, taking a step back to reflect on, update or extend understanding of that experience. In Chapter 5, the analysis of clinical accounts identified problematic reactions to the need to manage sexual boundaries whether identified as such by the participant themselves or the research team. These were: self-protective/defensive; moralising/omnipotent; neediness; and over-protective anxiety. The processes involved in these reactions suggested that the model of boundary containment remained apposite. A focus specifically on accounts of supervision experience and expectations for supervision indicated that practitioners have high expectations of the activity and of supervisors. There are several roles outlined for supervisors. Clinically, these comprise a focus on client benefit, management of the supervisory relationship and contracting, facilitating the development of the practitioners capacities for understanding and working therapeutically, and with theory-practice links. These mirror the practitioners own roles, and there are potential contributions supervisors might make to support and develop therapist work at any point in the process model described above. In addition, the supervisor is seen as providing a quality check and has a role in maintaining standards and ensuring ethical practice. This occurs by monitoring the therapists accounts and assessing their significance alongside their own experience of the supervision so that threats of boundary breaches might be brought into discussion, however difficult it might be for the therapist. Furthermore, participants not only affirmed the value of clinical supervision in order to help practitioners avoid or at least remedy breaches to the benefit of the client, but also felt that the supervisor had a responsibility to report unethical activity to the practitioners accrediting organisation, if it were deemed necessary for the protection of clients and the profession. While many of the accounts suggested that supervisors were found to be helpful, there were several instances of disappointment where participants had felt they were faced with criticism, where issues were avoided, or where supervisor guidance left them with unresolved feelings and even wondering about ethical dilemmas.

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The findings from this study, when compared with the literature on sexual boundary violations, seem to reflect similar themes. Our findings, drawn as they were, from a sample of participants who had managed to avoid sexual boundary violations, are consistent with literature that suggests that sexual boundary violations may not occur suddenly and that boundary breaches are likely to be the first steps toward sexual boundary violation (Somer and Saadon, 1999: Gorovitz (1982) cited in Sarkar (2004). Our sample was able to describe experiences of attraction and boundary breaches; the difference was that they took these minor breaches seriously as cause for concern and either acted to reinforce therapeutic boundaries or emphasised the need for reflection. The decisions made by practitioners reacting to a perception of threat, as recounted by participants, suggested they had differing degrees of awareness at the time of acting; some had come to regret the reaction and its effects on the client. In spite of this, and however the participant felt about their actions, none of these accounts could be construed as a description of a sexual boundary violation. The team were left with two conclusions; first, that some reactions to concerns over boundaries increased the practitioners understanding and resulted in further therapeutic development; and second, the actions taken by practitioners in an attempt to avoid sexual boundary violations sometimes resulted in a loss of empathic responding that was potentially problematic in its own right. In several examples, clients left therapy; in at least one, there was a suggestion that the event was a contributory factor in further mental health difficulties. Punitive responses and the potential for harm to clients have also been discussed by Simon (1999). The way that practitioners handle the experience of small boundary breaches therefore seems to have significance for skills development in future therapeutic work and may repay attention. The team developed a sense during the analysis of the characteristics of problematic reactions to threatened violations. These seemed to involve hostility or distancing, along with self-protection and reduced capacity to attend to the clients emotional experience, thus compounding a perceived change in the balance of power in sessions. Norris et al (2003) and Celenza (2005) suggest that difficulty working with aggression and other negative feelings may contribute to a defensive sexualisation, as the therapist attempts

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to avoid experiences of disappointment or hate. As there was some indication that anxiety and loss of emotional equilibrium had a part to play in determining the degree of empathic responding and in shaping the practitioner response (cf. Celenza, 2005) it seems logical that practitioners work might benefit from strategies aimed at reducing uncertainty and fear of exposure. There are implications both for training and accrediting organisations. An initial finding was the consistency of definitions at the extremes of therapeutic activity. There was universal opprobrium in relation to therapist-client sexual activity. Most felt that sexualising the relationship, touch and flirtation were unacceptable. There was some variation as the meaning and severity of the contact became less clear cut. For some therapists, the motivations of the therapist became crucial; when crossing a usual boundary, participants felt that it was important to understand these lapses, and supervision was seen as one resource for this reflection. This dimension makes it impossible to frame ethical guidelines in terms of specific actions; apparently innocuous actions may contain more sexual intent than more obvious ones. There is possibly a need to reflect on practitioners understanding of empathic responding. Common definitions emphasise the emotional component of the activity; empathy is understood as an ability to put oneself into the situation of the other and to feel as they do. It is this definition that is hard to separate from sympathy, and which emphasises the engagement end of the balance we have noted. Celenza (1995) offers a more complex definition, and one that fits with our own observations of clinician activity, with what we have called the participant/ observer stance. Celenza (1995; 305) writes: Empathy is a skill a simultaneous process of feeling resonant with the patient while remaining apart and observing ones own reactions. Using this definition, it is possible to see once again, the balancing act that clinicians aim to engage in, each time they enter a therapy session. It was of interest that constructive responses to threats to boundaries were not restricted to a sub-group of the participants; all gave examples of problematic responses and

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found that it often took some time before the experience was understood and processed sufficiently for constructive use in sessions. It did seem that experience played a significant part. Experienced practitioners did not appear to avoid boundary breaches entirely, but their descriptions suggested that they felt less unnerved by them as they occurred, and having learned from past experiences that they could be remedied, they were more confident to take such incidents routinely for supervision. None of the participants proved ignorant of the ethical principles and all recognised the value of core principles. Many were comfortable with the responsibility of balancing different and conflicting ethical concerns, and of finding supervisors or seeking consultations to make such decisions clearer. There were however, some areas of uncertainty. One of these is a difficulty managing the awareness that a colleagues practice may be unsound. Some of the examples given were compounded by the recognition that the evidence on which the colleagues conduct was under suspicion was flimsy, often coming from third parties or from intuition. Confidentiality also conflicted with the requirement to report; evidence came from therapeutic sessions, either as direct confession or in relation to contacts with another professional. Under these circumstances, the recognition that to report would compromise therapy made the prospect of reporting difficult in the extreme. Within the literature, touch is a contentious issue. Some practitioners prefer never to touch; for others it is integral to practice. Twemlow, 1997; Hetherington, 2000a&b: Casement, 1985 and Orbach, 2003 offer a range of arguments about the value and meaning of touch. In this sample, practitioners offered views across the range, but a tendency for a conservative view was clear, whatever the profession or modality, and some practitioners had moved from more liberal to more conservative positions over time and in response to experiences with clients. Furthermore, there was a clear theme concerned with meaning, with an emphasis on reflection, and attention to the meaning of desires to deviate or actual deviations from usual practice. This conservative stance, supported by theory for many as it was, may be a protective factor.

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Accounts of supervision demonstrated useful supervision as having two components, again required to be in appropriate balance, so that the practitioner was facilitated to think as constructively as s/he is able. When the practitioner had breached a boundary (or the supervisor suspected that this was the case) the supervisor engaged in two activities; normalising the presence of the feelings, on the one hand, and challenging the trainee to examine these in context and to question the experience, on the other. This process seemed to require as much capacity to respond empathically as the clinical work itself; and perhaps given the degree of anxiety and desire for self-protection felt by practitioners as they struggle through the process of making sense (as in Chapter 4), empathy is crucial.

Recommendations for practice The findings of this study were used to develop recommendations for practice. Some are drawn directly from the views and values of the practitioner accounts; others are developed from reflecting on the accounts of experiences in clinical work and supervision. Given that these are based on data from a single study, the recommendations have been framed as issues for reflection rather than directions. There were five key areas of practice identified: practitioners and their work, clinical supervision, employing organisations, accrediting bodies, and training organisations. 1) Accrediting bodies Accrediting bodies have an important role to play in sustaining individual practitioners links to a community of practice, offering practitioners a sense of belonging and identity and supporting professional and ethical standards. While it is accepted that this purpose is served both through publications and CPD activities, there may be a need to consider ways of making these palatable and even reassuring to practitioners, thereby ensuring maximum dissemination and ownership through the membership.

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It may be important for accrediting organisations to review their stance on the acceptability of personal and other relationships with ex-clients; and to make the outcome of such considerations available to members.

Given the findings of this report, which suggest that participants understand boundary breaches as regrettable, but often remediable and sometimes

therapeutically useful, there is a need for organisations to take into account the risks inherent in working in this domain. Whilst accrediting bodies have a duty to investigate alleged sexual boundary violations, it is important to remember that allegations are the culmination of a complex series of events, and sometimes misunderstandings. The practitioner is likely to be vulnerable, whether innocent or not; and the procedures bring additional anxieties, not only for the practitioner under investigation, but for colleagues and others in the profession. It would be helpful for there to be adequate supportive as well as investigatory structures within each organisation. The therapeutic management of boundaries and effective supervision require a capability in therapist or supervisor to think under pressure, and at worst, do no harm. Some participants highlighted the value of personal therapy; others commended active skills acquisition during training sessions. While it is recognised that there may be several pathways to the development of this capability, accrediting bodies might helpfully consider the role of experiences such as personal therapy and reflective practice, and guide training organisations and practitioners towards best practice. Given the relatively sparse and weak evidence base on the benefits of personal therapy, in spite of therapists own beliefs in its efficacy, and the anecdotal and clinical literature on the difficulties of reporting therapies (Szecsody, 1999), there may be a need to support further research in this area. It may be useful in the mean time to recommend pathways for personal development to promote alternatives or

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supplements to personal therapy for those practitioners who are not required to undertake personal therapy during training. Given the uncertainty expressed by participants about conditions and processes for managing third party reporting, it may be important to develop guidelines that outline the circumstances under which such reporting should take place. Guidelines should include information about the sources of information and the nature of the relationship with the client and colleague involved in a sexual boundary violation, the type and strength of evidence required, and the safeguards in place for protecting and supporting all concerned. Accrediting organisations may need to consider quality assurance for supervision, especially whether regular clinical supervision is mandatory, what training and supervision supervisors should undertake, and how those engaged in supervision might evaluate its value for clinical practice, and inform and support practitioners and supervisors. Practitioners who transgress sexual boundary violations, and are then disciplined, may be required to undertake a process of rehabilitation or disqualified from practice. There is little research evidence about the success of rehabilitation, and this would be a valuable addition; the model and themes described in Chapters 4 and 5 may contribute to the future evaluation of rehabilitation. 2) Training organisations Training on ethical guidelines is already included in courses for accredited psychological therapists. While the successful management of boundaries under pressure is perhaps best understood as a capability, programme teams might usefully review ways of increasing trainees skills in making use of these principles in clinical practice and in linking their own feelings and anxieties to their responses when faced with ethical dilemmas in clinical settings.

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It seems beneficial to address issues of sexual attraction in training, so that trainees understand that this is normal and the issue does not become the elephant in the room, something that provokes so much anxiety or shame that discussion becomes impossible. This might also include discussion of differences in assumptions deriving from cultural expectations, for example, about touch and self-disclosure.

Training organisations may consider adopting the process model described in Chapter 4 into a template for evaluation of clinical skills development. Students who do not learn to work through this process may need remedial skills training or supervision.

3) Employing organisations Within our sample, there was no resistance to the concept of accreditation, or rejection of the existing ethical standards. It was interesting to note, however, the varied pathways to accredited status and work conditions described by participants. For many, their training had taken years; they had self-funded part or all of training, therapy and supervision. In this sense, these participants form a sample unusual in comparison to the majority of public sector staff, where support to undertake accredited trainings may be limited. If public sector organisations require staff with the capabilities to manage boundaries under pressure, and to assist staff with less training and experience in doing so, they may need to review the demand for practitioners accredited through therapy organisations, and the systems for supporting staff in the acquisition and maintenance of this level of expertise. Employing organisations might review policies and procedures to ensure that staff are well informed about ethical and organisational expectations of boundary keeping, supported and supervised in their clinical work, and that there are clear, humane and just procedures in place for investigating alleged boundary violations. It would be beneficial to consult widely so that staff are included in the development of policy in relation to clinical practice and can develop a sense of ownership of policy.

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Practitioners may become more vulnerable when feeling disempowered or stressed; change management is likely to be an important feature for maintaining clinical standards, and keeping clinicians involved with service development may serve a protective function. Staff moving into new work settings, and those staff who feel demoralised, may be more vulnerable to boundary breaches, anxious about disclosing them, and find them more personally satisfying. Line managers in particular may be well placed to help staff manage this vulnerability more constructively.

Morale and self-esteem may have a part to play in the practitioners capacity to withstand pressure on therapeutic boundaries: it would be advisable for managers of services to consider the resources and organisational culture necessary for these to be maintained. For example, it may be necessary to consider the balance of a practitioners caseload, so that no one professional group or individual is always required to take on the clients that practitioners find difficult or draining to see.

4) Clinical supervision Given the number of tasks and complexity described in good supervision, supervisors might consider how to gain competence in and maintain the quality of the supervision they provide. This might involve training and supervision of supervisory practice. In parallel with practitioner values, the supervisor would do well to develop a clear understanding of the rationale for the boundaries required between supervisor and supervisee. A formulation of the practitioner and their learning needs and vulnerabilities might be a helpful aid for noticing difficulties early. In particular, an understanding of the way the practitioner manages emotional needs, such as needs for intimacy, success or recognition may be useful. In our sample, there were instances of difficulty in supervision attributed to different views on boundaries, including where the boundaries lay. When potential

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disagreements about the significance of actions arise during discussion of clinical work, these may raise anxieties in supervisees. One example from our sample that seemed particularly anxiety-provoking to practitioners was the pairing of a supervisor who believed that boundary breaches such as touch were problematic and the practitioner who had a more liberal interpretation and felt undermined by the supervisors approach. Under such circumstances, the supervisor may need to estimate whether a successful supervisory relationship will develop, and make decisions on the basis of their assessment. Whether or not there are differences in choice of therapy framework, supervisors need to be proactive in addressing the supervisees anxiety, embarrassment and shame, recognising that the practitioner may feel the need to minimise, disguise or avoid difficulties. The concept of a tension between reassurance and normalising on the one hand and suspicion and challenge on the other, may be helpful in guiding the supervisor through the process of inviting disclosure and exploration. This was highlighted by one participant in our sample, who contrasted two supervisors, one who normalised, while the other challenged to a degree that felt pathologising; neither was experienced as able to combine the two and help the practitioner manage such situations effectively. It seemed that our participants valued the opportunity to discuss embarrassing or worrying experiences in supervision over time. One possible strategy for supervisors who are concerned to facilitate discussions of clinical work in which anxiety and intense emotional states arise, would be explicit discussion when agreeing to take on a new supervisee. This discussion might usefully acknowledge the possibility that sexual attraction is one of the experiences that are likely to arise in therapy and that the supervisor aims to offer a safe setting in which to explore the meaning of such events. Formal contracting may helpfully include these areas.

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Some of our participants noted periods of increased vulnerability. Some clients seemed able to affect the practitioners behaviour; life circumstances sometimes contributed. Single status and marital dissatisfaction were mentioned specifically. These contributed to an illusion that client and practitioner needs might be satisfied by breaching boundaries. Supervisors might bear in mind, not the personal circumstances of the supervisee, but the supervisees experience of those personal circumstances and the meaning attributed to them, as part of their analysis of the total situation. Supervisors may need to consider how to best offer advice on the management of personal distress.

5) Practitioners and their work Given the universal recognition that sexual relationships between therapists and their clients are harmful, practitioners need to seek and actively develop an understanding of this prohibition, and a rationale for adhering to it based on values and benefits rather than threat alone. Furthermore, practitioners need to develop an

understanding of the function of other boundaries, including time, setting and touch, recognise their own attitudes towards these and develop strategies for managing them. Once their values are relatively clear, practitioners need to develop a sense of the degree to which they comply with and work within appropriate boundaries; of the circumstances (if any) in which they are prepared to be flexible; and a default position, deviation from which would indicate a boundary breach, thereby initiating a process of reflection and if necessary, supervision. Self- care and a capacity to reflect on ones own activity are important considerations, often mentioned in ethical guidelines. Practitioners successful in managing threats to boundaries seemed to have one or more of these characteristics: a satisfying life and good relationships; a capacity to reflect on their own emotional needs and the ability to recognise their own vulnerabilities; and a

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preparedness to admit the need for measures to maintain their fitness for practice, whether in terms of adopting personal strategies or taking major steps such as entering therapy, taking further steps to promote good practice, especially training or supervision, or changing some element of personal life or practice. Clinicians are advised to consider their own need for supervision. A match between the values, mode of delivery, therapeutic framework and styles of practitioner and supervisor may affect the use it is possible to make of supervision. The requirements of a practitioner may change over the course of time. The quality of the supervision itself seemed to be important; practitioners need to feel confident that discussing boundary issues, especially sexual boundary issues, will be met with a response that enables the practitioner to benefit from supervision. Committing to a supervisor is therefore an important decision; it may be helpful to discuss the supervisors approach to the issues at the start, and to review regularly the extent to which supervision continues to offer a secure and exploratory experience. Practitioners are responsible, once qualified, for their professional conduct. This makes it imperative that they take responsibility for discussing boundary breaches in supervision. When the practitioner finds this discussion is compromised, whatever the reason, it may be advisable to consider requesting a consultation or finding an alternative route for reflection rather than ignoring even a minor boundary breach. Given that practitioners recognise the possibility and desirability of using the understanding of minor boundary beaches for therapeutic benefit, and that such events may have symbolic meaning that develops such understanding, it is the practitioners responsibility to offer these for discussion in supervision, however embarrassing; this may include dreams and fantasies as well as actions. Clinicians, along with their trainers and supervisors, may find the model developed in Chapter 4 and the typology in Chapter 5 useful for reviewing how they are managing

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clinical situations where is a threat to the boundaries, through difficulties in working with attraction.

Strengths and limitations In this section, there is a brief outline of the teams assessment of strengths and limitations of the study, in order to provide the reader with some of the information required for deciding on the merit of the findings and recommendations. The study design was innovative; it allowed the generation of rich data, including detailed accounts of a range of clinicians struggles in the face of sexual attraction within therapy, their understanding of these events and their reactions to these experiences, including boundary management and therapeutic strategies. The data was apposite to the research questions, and the research team were able to identify meaningful themes and develop models demonstrating the complex processes and relationships implicit in the interviews. The sample comprises practitioners varied in terms of therapeutic orientations, training, years in practice, client groups, working arrangements and environments, types of experience, age, sex, sexual orientation, and location. There is limited cultural and racial diversity, although there is some; this may reflect, however, the characteristics of the population of practitioners. This variety within the sample facilitated the collection of a range of views and responses to the research topic, and required the team to develop the findings in language that would be meaningful for practitioners working with different models. The adoption of several strategies for recruitment not only enabled clinicians with an interest in the topic area to come forward, but also allowed the inclusion of practitioners who had experience and expertise in the topic area, but who might not have felt sufficiently strongly to volunteer themselves without the request to do so. This sub-sample may increase the degree to which the findings can be seen as representative of the body of clinicians.

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The size of the sample had both benefits and drawbacks. The number of interviews was large for a project of this type and duration; the complexity of the analysis required time, and the period of data analysis became extended and pressured. Conversely, the sample size is small and in order to generalise from the sample to the population of practitioners, it would be advisable to consider the characteristics of this selected group. The final sample was older, more evenly balanced in terms of gender, and had possibly experienced longer and more intensive training than the average practitioner. From this sample, it is possible to draw conclusions salient to the practice of the clinician who is drawn into sexual boundary violations because of personal difficulties or skills deficits (the troubled clinician) but the findings are unlikely to be as relevant for the entrenched serial transgressor. The differences between the team members shaped the collection of data and analysis. All researchers collected data; there was variability in interview style and focus; this meant that some areas are covered more intensively in a subset of the interviews. Given the analytic strategy, this need not be considered a limitation; the team prioritised the appearance of a theme over the extent to which this theme was present in the sample as a whole. The analytic strategy incorporated additional data, generated through consideration of memos, records of debriefing meetings, and discussion between analysts. This allowed the analysis to incorporate the interviewers reactions and understanding into an interpretative account of the data. An initial experiment with computer-assisted analysis only confirmed the need for manual analysis. The range of backgrounds of the team acted to keep the analysis grounded in the data; as we experienced the full extent of challenge and debate necessary for consensus, it clarified each individuals taken for granted assumptions to a greater degree than is perhaps usual.

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Prior to the report, the findings have been offered to a small number of individuals and groups, including a workshop in the BACP Annual conference (2009). These did not seem alien to audiences. While there was a comprehensive and valuable report covering the research evidence published only recently, the team commissioned a more specific systematic literature review. This review, and the subsequent analyses of the literature it generated, has contributed to the discussion of the findings.

Future research There are similarities between the findings of this study and the reflective literature, which strengthens our conclusions and recommendations. However, as the sample is small and selected, it is likely that conducting similar studies would give some indication of the extent to which the findings from this study are representative of practitioners as a whole, and of how applicable they might be to therapy and counselling generally. In line with Twemlows (1997) recommendations, there may be value in exploring the relevance and influence of cultural factors. When designing the study, the team were concerned that accounts given by practitioners who had been engaged in sexual boundary violations might be different; there might be different attributions made, in order to preserve a positive self-image or selfesteem, for example. There might be useful conclusions to be drawn from exploring such accounts for thematic differences. These findings may have implications for developing and assessing procedures for rehabilitation. In reviewing the evidence base, it is noteworthy that one of the consistent risk factors is being male. Our sample was evenly divided between men and women, and there were examples of attraction to clients in all accounts, regardless of the sex of the participant; issues of sexuality and management of feelings of attraction to clients were common to both

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male and female therapists. Furthermore, both male and female therapists gave examples of attraction to both male and female clients; and the practitioner might be either homosexual or heterosexual. What became clear was that issues of attraction and sexual elements in the experience of relationships within therapy were present for therapists regardless of the sex of therapist or client. One issue raised by several participants was the tendency to understand a parental, and in particular, a maternal response to clients as defensive or selfprotective. Given that defences offer indirect rather than direct expression or avoidance of feelings, it is possible that this particular defence, with the emphasis on nurturance, may become part of a slippery slope which if not remedied, may lead to boundary breaches. In particular, physical contact, for example, the hug intended to comfort or reassure, may be considered relatively unproblematic when experienced in conjunction with maternal feelings. There are also indications in the literature of more complex relationships between feelings of attraction and sex in other papers. For example, Pope, Keith-Spiegel and Tabachnick (1986) noted differential response rates when surveying 1000 psychologists, with men being more likely to respond than women (68% compared with 49%). Men reported being attracted more by physical characteristics, and women by success. They also commented on a recent increase in malpractice suits against women therapists in the US which they thought might reflect an increased preparedness to accept that women may also transgress. If female therapists are at risk, it behoves future research to focus on the complexities of the dynamics in therapeutic relationships for therapists of both sexes. The findings from the literature on client experiences of TCS and from this study might usefully be extended or qualified through the study of boundary breaches in detail, through direct observation or analysis of other data sources,, such as client records. It may useful to identify the most common errors and the most easily used strategies for success; the findings may have a role in enabling staff from training programmes to support the development of positive strategies.

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It may be useful to explore the subjective experiences of clinicians undergoing training in the management of boundaries and in managing ethical dilemmas, to facilitate more successful training, and to identify indicators of successful internalisation of an ethical stance, over and above compliance with the rules. Given the importance attached to supervision as an aid to the successful management of boundaries, there may be value in exploring the factors that contribute to an effective supervision process. Given the possibility of using therapy and supervision in rehabilitation, it may be worth testing the utility of the model generated in Chapter 4 and the typology of reactions to threat identified in Chapter 5 in evaluations of the rehabilitation process.

Conclusions The majority of practitioners in the sample were aware of the universality of sexual feelings and the likelihood that attraction would occur during some therapeutic contacts; this was not seen as problematic or shameful, and the emphasis was on the meaning of and response to such feelings. The process identified for recognising signals that might lead to sexual boundary violations and then resolving them is described in Chapter 4. Signals included anxiety and unease; sexual attraction and sexual conduct outside the normal range of the practitioner, e.g. flirting; minor boundary breaches that indicated pressure on the therapy boundaries; and the need for increased understanding of the interpersonal element of the therapy session. Practitioners used a number of resources; some mentioned training and clear ethical guidelines; others had developed frameworks for making sense of sexual attraction and sexualised behaviours. In particular, some therapists understood sexualised relationships as protective strategies. Whether experienced by client or practitioner, sexual feelings were often seen as masking or communicating about other conflicts or needs. These included attempts to avoid loss, separation, helplessness or abandonment; reluctance to face the clients disappointment or anger, or strategies employed to manage self-esteem

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and self-worth. These frameworks facilitated the endeavour to make therapeutic use of boundary breaches to the benefit of the client. Good supervision was seen as crucial for this process; the ideal was to develop an internal supervisor who would assist the practitioner make more effective interventions and protect therapy through management of the boundaries. Experienced practitioners described a process of working through clinical situations that required them to process their experience and reflect on it to the clients benefit. The participant/ observer stance identified as essential for this process to work well is compatible with Celenzas (1995) definition of empathy, which also points up an experiential and a reflective element. Even when such frameworks and supports were unavailable, these practitioners were able to avoid sexual boundary violations. A typology of four reactions to the clinicians perception of a threat to the boundaries involving attraction was apparent in the more problematic examples. These sometimes served to prevent development of a SBV, through for example, a return to ethical guidelines; there were examples of explicitly reaffirming boundaries. There were unfortunate consequences for clients or the therapy process, however, in some examples of this; some practitioners regretted the interventions they had made and felt that they had learned from reflecting on their experience and conduct. In other examples, the experience of providing the therapy was costly and perhaps risky, as the practitioner struggled to work and contain their own feelings of neediness and distress during the period of attraction. In conclusion, clinicians experience a number of issues to balance to keep and tensions to manage. When taken to supervision, this is recreated, and the supervisor has a role in helping the therapist contain anxiety and understand the significance of their experience. While personal characteristics and vulnerabilities may play a significant part in sexual boundary violations, something that this study did not set out to answer, these participants found a variety of ways, more or less successful, through the clinical situations they faced. Their accounts stress the value of supervision and training in the management of

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the ethical dilemmas that boundary breaches give rise to, and of theoretical frameworks that allow an understanding of what is not explicit in therapeutic sessions.

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Appendix 1
Systematic Review: (a) Exclusion and inclusion criteria Table 1: Exclusion and inclusion criteria for literature search Exclusion Criteria Timeframe 1997 - 2008 Narrow search criteria to include only studies from the last 10 years to reflect evolving ethical issues and published guidelines. Current review aims to focus on specific practitioners: Counsellors, psychotherapists, clinical psychologists. Rationale The ethics and guidelines are updated regularly. The last BACP guidelines were published April 2007, APA published 2002. Scoping search found many studies focussing on other types of healthcare professionals: physicians, GPs, nurses. Will use papers where majority of therapists specified are described in the current reviews research question. Supervisor-supervisee considered a sufficiently distinct context and so is omitted from the current review. Rationale Unpublished research will not be included as is not peer reviewed. Quality control of using peer reviewed studies (Number of dissertations /conference proceedings (2), book chapters (4) reported but not reviewed.) Inability to read the content of papers in language other than English. (Only one paper - in German - was found that had no English translation.) Exclude papers concerning other areas of sexual boundary violations such as legislation as beyond scope of current study.

Type of practitioner

Supervisor-supervisee relationships

Current review concerned with therapist-client relationships.

Inclusion Criteria Published work

Language of study

Only papers in English, or in English translation, considered.

Indicators leading to sexual boundary violations

Select papers with main focus as indicators and prevention of boundary violations.

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(b) Search strategy (includes empirical and reflective papers) Table 2: Search criteria used for PSYCINFO Search terms Tota l no Exclusion Number of criteria papers 1997reviewed 2008 615 439 Reviewed all Reasons not relevant/Excluded from SSR Releva nt papers 9

1 Sexual boundary violations 2 Therapist sexual misconduct 3 Professional client sexual relations 4 Professionalpatient relations 5 Professional misconduct 6 Patient abuse

545

303 Reviewed all

657

383 Reviewed all

56

36

187

40 Reviewed all, none relevant 22 Reviewed all, none relevant 93 Reviewed all

Books, book reviews, Russian, supervisors/supervisees, social workers, legal papers, dissertation papers, physicians Replicated from previous search (7), trainee/client relations, books, clergy, sexual addiction, prison violence, dissertations Books, sexual abuse (non therapeutic situations), sexual orientation, general sexual behaviour studies, HIV, drugs Medical students, general medicine, books Legislative reviews, nursing, medical students, physicians Psychiatrists, books, nursing homes

(7)

Total number of original relevant papers (and papers found in previous search) PSYCINFO

11 (7)

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Table 3: Search criteria used for Web of Science Search terms Total no Exclusion criteria 19972008 Conference proceedings Number of papers reviewed Reasons not relevant/Excluded from SSR Relevant papers

1 Sexual boundary violations 2 Professionalpatient relations 3 Therapist misconduct

111

61 Reviewed all 72 Reviewed all 25 Reviewed all

94

47

4 Precursors misconduct 5 Indicators misconduct 6 Professional client sexual relations 7 Practitioner ethics

1 7 3

1 Reviewed all 7 Reviewed all 3 Reviewed all 148 Reviewed all

Boundary violations of physicians, German, medical students Medical illness, legal based papers, hospital patient experiences, brain injury Replicated from previous search (4), student nursing studies, German, legislation, non sexual boundary violations Replicated from previous search (1) Prison behaviour, police misconduct Social work, medicine, victimisation of women Issues of participant consent, substance abuse, Hippocratic Oath, doctor-patient conflict, suicide, medical ethics Total number of original relevant papers (and papers found in previous search) Web of Science

1(4)

(1) 0 0

179

6 (5)

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Table 4: Search criteria used for MEDLINE Search terms Total no Exclusion No. of criteria papers 1997 reviewed 2008 531 380 Reviewed as far as 250 684 Reviewed as far as 300 Reasons not relevant/Excluded from SSR Relevant papers

1 Sexual boundary violations 2 Practitioner misconduct

1079

3 Sexual misconduct

1128

710 Reviewed as far as 300

4 Professional client sexual relations 5 Professionalpatient relations

593

376 Reviewed as far as 300

149

95 Reviewed all, none relevant

Legal, physician-client relations, traffic violations, psychiatrists, medical based lit Previously found in other databases (2), GP misconduct, legal, scientific/research misconduct Obstetricians & Gynaecologists, previously found in other databases (3), trainees, medical practitioners not relevant to current SSR, clergy, nursing, scientific misconduct Nurse-client, social workers, sexual health, sexual behaviour, gender, sexual health, sexually transmitted infections, condom use Informed consent, patient confidentiality, medical students Total number of original relevant papers (and papers found in previous search) MEDLINE

(2)

(3)

5 (5)

Table 5: Search criteria used for Social Care Online Search terms Tota l no Exclusion No. of criteria papers 1997 reviewed 2008 1 1 Reviewed all abstracts 8 5 Reviewed all abstracts 3 3 Reviewed all abstracts 0 0 47 Reviewed all abstracts 1 Reviewed all abstracts Reasons not relevant/Excluded from SSR Relevan t papers

1 2 3 4 5

Boundary violations Professional misconduct Sexual misconduct Therapist misconduct Sexual abuse and ethics Vulnerable adults and sexual abuse

Treatment of sexually abused children Social workers, victimisation of whistle blowers Teacher-student boundary violations, social workers Clergy, psychiatrists, social workers, sexuality, learning disabilities, foster care Legal concerns for adults with LD

0 0 0 0 0

61

Total number of original relevant papers Social Care Online

95

(c) Effectiveness of search: empirical studies (reflective papers excluded from table) Table 6: Summary of effectiveness of each database and hand searching

Author (date) PSYCINFO Ben-Ari & Somer (2004) Celenza & Hilsenroth (1997) Celenza (1998) Moggi et al. (2000) Somer & Nachmani (2005) Somer & Saadon (1999)

Source of papers Web of MEDLINE Social Care Science Online

CHRE review references X X X

X X

X X

X X 0 5 Papers from review = 5

X X 3 2 1 Total original papers from online databases = 1

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(d) Summary of empirical papers Table 7: Summary of the empirical papers Research er (Date) Moggi et al. (2000) Journal Count ry Switze rland Design Data/ Evidence Sample Key aims of paper To examine patient sexual abuse risk factors & assess psychological consequences Indicators identified Implications for findings Neither personality factors nor circumstances during psychotherapy are directly predictive of sexual abuse. Processes are more subtle & need research Methodologic al quality Good sample size due to anonymity of questionnaire; large n means high generalisability; well matched control group; reliable (high Cronbachs ) & valid questionnaire; participants missing data excluded from analysis; selection bias due to participant motivation Small sample size; no control group; self selected but information rich. Author is trained & experienced

Clinical Psychology & Psychother apy

Survey

Primary data from research questionnaire

100 women: 57 sexually abused by psychothera pist, 43 controls

Focus on client characteristics Paper finds that attention should be directed to identify combinations of factors rather than focusing on individuals determinants. These include : characteristics of therapists/clients & the settings & processes in therapist-patient relationship that may lead to SBV in psychotherapy

Ben-Ari & Somer (2004)

Clinical Psychology & Psychother apy

Israel

Qualitati ve

Primary data from semistructured interviews

14 women patients engaged in TCS

To help participants through a personal transformation to confront painful TCS experience

Focus on client characteristics Emotionally deprived, difficulties with relationships (especially fathers & male partners), problem saturated, in crisis, lonely, low self-

Awareness of patients at risk: new female patients, low self confidence, previous abuse (refer to

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(from victim to survivor)

esteem, lacking in self confidence

Somer & Nachman i (2005)

Sexual Abuse: A Journal of Research & Treatment

Israel

Quantita tive Qualitati ve

Primary data from questionnaire completed via phone (n=11) or in person (n=13)

23 female patients & 1 male patient engaged in TCS

To investigate experiences of psychotherapy clients emotionally & sexually exploited by therapist

Focus on client characteristics All felt exploited & betrayed by therapist. Client perceptions (romance/abuse) of TCS affect pre-, peri- & postemotional well being. Romance group buffered against negative effects during relationship but suffered severe deterioration in emotional well being after sexual contact ceased. Romance group emotional well being better at all time points (before, during, after TCS) than those in abuse group

experienced female therapists). More media coverage to empower victims to report abuse Future research to compare abuse histories, defence mechanisms, & psychological symptoms of TCS-Romance & TCS-Abuse

clinician; study involved therapists other than those specified in research question Small sample size; participant selfselection; problems with retrospective nature of design (8years past so participants may reformulate memory reconstructions & report inaccurate perceptions & feelings about experience).

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Somer & Saadon (1999)

Professional Psychology: Research & Practice

Israel Qualitative Primary data Quantitative from research questionnaire

27 women patients engaged in TCS, 26 control women patients attending Israel Institute for Treatment & Study of Stress not engaged in TCS

To improve effectiveness of therapists through increasing understanding of factors that contribute to SBV

Focus on therapist characteristics Profile of therapist at risk for SBV: reputable, middle-aged, mainstream, male psychologist, working alone in private practice. Recommendations to prevent SBV: consider small increments of actions leading toward erotic intimacy, conduct therapy in setting shared with others, special care to maintain clear boundaries especially if client was victim of child abuse, mandatory consultation & peer supervision (requirements for license renewal) Focus on client characteristics Distinct risk client group who have been traumatised in their past, as children, exposed to emotional neglect/sexual abuse, problems in previous interpersonal relationships

Recommended that regulation boards develop strategies to address more mature professionals at risk of personal crisis, depression, or burnout. Mental health professionals need routine screenings for childhood trauma

Limitations of small sample size, however control group well matched; problems of retrospective design as average of 7.7 years past since TCS so memories may have been effected by factors such as how they dealt with feelings towards therapist; subsequent unrelated negative life events occurring after experiences may have been attributed to negative outcomes from TCS

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Celenza (1998)

Psychoanalytic USA Psychology

Qualitative Data from Quantitative consultations, supervisions, treatments

Celenza & Bulletin of the Hilsenroth Menniger (1997) Clinic

USA

Qualitative Primary data Quantitative assessed by Rorschach protocols

Focus on therapist characteristics Longstanding & unresolved problems with self esteem, sexualisation of pre-genital needs, restricted awareness of fantasy, covert & sanctioned boundary transgression by a parental figure, unresolved anger towards authority figures, intolerance of negative transference, defensive transformation of countertransference Focus on therapist 20 mental Identifying health characteristics characteristics professionals of Profile comprising several engaged in transgressing related personality sexualized therapists & characteristics & dual rehabilitation vulnerabilities. relationships potential Significantly higher levels of distress specific to interpersonal longing & helplessness, 17 mental health therapists sexually involved with patient Explores characteristics & predisposing factors in therapists who transgress SBV

Need for less punitive atmosphere within therapy profession so therapists feel free to seek help before SBV occur

Awareness of personal vulnerabilities within therapists, especially with regards to future training

Small sample; multiple and rich data sources; comprised individuals referred from a range of sources i.e. those that identified by others or by themselves as sexual boundary violators. Small sample; involved therapists other than those specified in research question; unmatched control sample of 700.

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Appendix 2
UNIVERSITY OF LEEDS Research into practitioners experiences of successfully managing the risk of sexual boundary violations with clients Information sheet This Information Sheet is designed to provide you with information about this study so that you can decide whether you would like to take part. It provides an overview of the study and of what would happen if you decided to participate. The purpose of this study and the research team This study has been commissioned from the University of Leeds by the British Association of Counselling and Psychotherapy (BACP). The purpose of the study is to investigate how practitioners understand sexual boundary issues in their therapeutic encounters and how they manage the boundaries when they experience feelings of attraction towards clients. We are seeking to interview practitioners about experiences of sexual attraction to clients in therapy and in related activities such as supervision. We wish to explore with practitioners examples of situations that have been experienced as sufficiently problematic to require thought and psychological work, but not to the extent that the accepted sexual boundaries have been breached. Our particular focus is on developing understanding of the resources, strengths and strategies that practitioners draw upon to manage threats of sexual boundary violations and the factors that might enhance or compromise the use of these. We are a team of researchers based at Leeds University with experience of practice or research into psychological therapies and counselling. The team members are Mary Godfrey and Carol Martin, Leeds Institute of Health Sciences; Anna Madill, Institute of Psychological Sciences, and Bonnie Meekums, School of Healthcare, University of Leeds. What contribution will the research make? The findings will be developed into a report for the BACP and guidelines for practitioner members. The aim is to support practitioners to manage emotionally demanding therapeutic situations within the professional boundaries they adopt as part of their professional practice, and to contribute to academic and professional debate through further publications. What is the timescale for the research? The final report should be developed during the summer of 2009 for sending to the BACP in September 2009. What happens if I decide to take part? If you decide to take part we will arrange an interview with you at a location convenient to you at a mutually convenient time. The interview will take about an hour to an hour and a half. If you agree, the interview will be audio recorded, and notes taken. If you would prefer to be interviewed by a male interviewer, please let us know and this can be arranged. It is obviously up to you to decide whether or not to take part. If you do decide to take part you will be asked to sign a consent form. If you decide to take part you are still free to withdraw at any time and without giving a reason. If for any reason, you feel uncomfortable during the interview, we will respect your wish to stop at any point.

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What will happen to the information I provide? No identifying details will be attached to transcripts. Personal details such as names and places will be kept separate from transcripts so that the interview content will not be identifiable with individuals. All data will be kept secure, anonymised and password protected, and will be destroyed after completion of the study and publications. What will I be asked about? The researchers are aware that sexual boundary violations with clients contravene the codes of ethics and practice to which practitioners adhere, and that for some of the team, their codes of ethics require that a serious breach of boundaries, particularly if there is potential future or actual harm to others, is reported. However, the focus of this study is on successful management of therapeutic boundaries; the interviewer will not ask you to provide information on actual breaches of sexual boundaries. Further, if the interviewer feels that the interview may be going that way, they will let you know, so that you have the opportunity to avoid disclosing details of sexual boundary violations that might require reporting to a professional body. What are the benefits and risks of taking part? As with similar studies that are concerned with emotional and sensitive issues, there is the potential for distress. If you show signs of distress, the interviewer will discuss whether it is appropriate to continue and possible alternative arrangements if the interview needs to be drawn to a close. In such studies, however, it has often been noted that participants state that the opportunity to reflect in confidence and to contribute to potential future benefits is worthwhile and of value to them. Who has given permission for the study to go ahead? This research is subject to ethical guidelines as set out by the BACP and the British Psychological Society and has been approved by the Ethics Committee within the Leeds Institute of Health Sciences, University of Leeds. These guidelines include principles such as obtaining your informed consent before conducting an interview, notifying you of your right to withdraw and of the protection of your anonymity. What if I have a complaint about the study? If you have any concerns about your involvement in this research you should, in the first instance, raise them with the researcher conducting the interview or with whom you have spoken or e-mailed. If you wish to make a complaint you can do so by contacting Mary Godfrey, Leeds Institute of Health Sciences, 101, Clarendon Road, University of Leeds, Leeds LS2 9LJ.

Thank you for taking the time to read this leaflet. If you are interested in the study and have any further questions, you will find further information on the LIHS website (http://tinyurl.com/9rr8v2).

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Appendix 3
UNIVERSITY OF LEEDS Consent Form Study title: Research into practitioners experiences of successfully managing the risk of sexual boundary violations with clients The purpose of this form is to make sure that you are happy to take part in the research and that you know what is involved. Please confirm each statement by putting your initials in the associated box. I have read the participant information sheet and have had the opportunity to ask questions and to discuss the study I have received satisfactory answers to all of my questions and have received enough information about the study I understand that I am free to choose not to answer a question, to end the interview and to withdraw from the study at any time without having to give a reason I agree to the interview being audio-recorded I grant permission for extracts from the interview to be used in reports of the research on the understanding that my anonymity will be maintained I understand that should I reveal information that describes a breach in professional boundaries that would normally require investigation, that the interviewer may be obliged to report this to my professional organisation; he or she will inform me that there will be a discussion with the team and of the decision to report I agree to take part in this study Participant signature Date Name of participant Researcher signature Date Name of researcher

Thank you for agreeing to take part in this study.

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Appendix 4

Have you experience of successfully managing sexual attraction to your clients or supervisees? We hope to interview a group of practitioners who have learned skills and strategies from their practice, and are interested in finding out what helps them keep within accepted ethical and professional boundaries. This is a research study carried out from the University of Leeds, commissioned by the British Association of Counselling and Psychotherapy. If you are interested in taking part, or would like to know more about the study, please look at our webpage: http://www.leeds.ac.uk/hsphr/psychiatry/courses/dclin/staff_research_projects.html Or you can contact us by telephone: 0113 3432732

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Appendix 5
Interview topic guide Stage 1: Introduction and basic information Thank you for agreeing to meet me today and offering to take part in this study. I would like first to outline the study and go through the information sheet with you, so that you are able to decide whether you wish to proceed further. There are no right or wrong answers to anything I ask you. [Consent form; Basic information- might be collected here or at the end of the interview- to include training, nature of client work undertaken, years of experience, current roles] Stage 2: main interview 1. I wonder if we might start with your own interest in this area: I wonder if you would tell me what led you to come forward for this study? 2. What is your understanding of a sexual boundary and of sexual boundary violations in clinical practice? Normal or usual limits on touch and sexual behaviours? Rationale for having an embargo on sexual contact with clients? Rationale for permitting or using physical touch, flirtation or similar behaviours in therapy with clients or ex-clients? What makes for a risky situation? What predictable features might there be that contribute to a risky situation? 3. We know that you agreed to take part because of personal experiences of having successfully managed feelings of sexual attraction to clients. Please would you tell me about one? 3a. What did you first notice? Please could you say something about your reactions? What sense did you make of this? What were your concerns/anxieties at this stage? What was your therapeutic work with your client like at this point? 3b. What quality did the feelings have, at first and as they developed over time? What feelings did you have? How did you understand these feelings? I wonder if you would say something about how these feelings compared to feelings you had or have for other people to whom you have felt sexually attracted (similarities/ differences in quality)? Please would you say something about how these affected you personally? And in your work? 3c. What else was going on in your life at this time? When did this happen? (sources of stress/anxiety; challenges to self esteem; disturbance in relationships; transitions) 3d. What did you do when you first noticed your feelings of sexual attraction? N.B. These might include: Internal management and self-control Changed understanding and reformulation

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Changes to the therapeutic setting or to practitioner behaviour Help seeking Making changes to conditions external to the therapy 3e. How did the situation develop? What was it like for you when working with this client? What did the client know and think was happening? What difference did it make to your therapy work? What difference did it make to other parts of your life? 3f. I would like to know how you managed this part of the experience. What did you contemplate doing that you would not normally do? What did you actually do? What did you find yourself not doing that you might normally have done? 3g. What use did you make of your professional and ethical codes? I wonder how you felt about the limits on sexual relationships with clients set by your codes at this time? What was your understanding of these limits at this point? What was the line you contemplated crossing? (i.e., what would have constituted a sexual boundary violation?) And what response you felt you might have from others to your situation? And how were these understandings different to the time before, and then after this situation? 3h. How did the situation resolve? What made the difference? What sense does this event have for you now? What did you learn from this experience for your therapy work and for the benefit of future clients? Or about yourself and your own life? How close were you to crossing the boundary at any time? I wonder what you feel now that this situation is over. General prompts: What did you do next? I wonder what you felt at this point? What sense were you making of things at this time? Would you say more about [thoughts, feelings, views, situation, behaviour, etc.]? 3i. I wonder whether you have further examples? If so, revisit the earlier questions and repeat for each example. 4. Overall, what do you feel makes it possible for you to work successfully when there are potential threats to therapeutic boundaries, and to work constructively with sexual attraction in therapy? What would you have done differently if you knew then what you know now? What benefits are there for clients when you as a therapist feel some attraction? How significant are the risks for clients; for therapists- and how has this changed for you with increased experience? What might have helped you seek help or stopped you seeking help? What more do you feel the professions could offer which would help practitioners facing the issue of sexual attraction to clients? What would you advise other practitioners facing this situation?

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Stage 3: Ending 5. Is there anything further that you feel you have not yet been able to tell me and that you think would be useful? Thank you for taking part. [Arrange second meeting if needed; copy of findings; expenses; basic information if still to be collected; offer that if they have more to say afterwards they can have a follow up phone conversation and give a means of contact.]

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Appendix 6
Mary Godfrey Leeds Institute of Health Sciences Charles Thackrah building Leeds University 101 Clarendon Road Leeds LS2 9LJ

25th February 2009 Dear Mary, Thank you for submitting your revised research proposal Managing risk of sexual boundary violations in counselling and psychotherapy for ethical review. The opinion that you obtained from the NHS REC queries line, along with the view of Professor Shickle, Chair of the Faculty Research Ethics Committee, provides confirmation that your proposal falls within the remit of the LIHS/LIGHT Research Ethics sub-committee. I am pleased to be able to inform you that reviewers acting on behalf of the sub-committee have now granted ethical approval to the above named research proposal.

Kind Regards

Laura Stroud Co Chair LIHS/LIGHT Research Ethics sub committee Leeds Institute of Health Sciences Charles Thackrah Building 101 Clarendon Road Leeds LS2 9LJ

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Appendix 7
University of Leeds Research into practitioners experiences of successfully managing the risk of sexual boundary violations with clients Guide for transcribers Please make sure that you have signed a copy of our Confidentiality Statement for Transcribers form, returned this signed copy to one of the researchers, and that you follow the procedures specified on the form. Thank you. In order to help the researchers analyse the transcripts you produce, we would be grateful if you would follow the guidelines for transcription set out below. It is helpful to us if our transcripts are consistent and following these guidelines will facilitate use of tools such as search strategies on the software package we will be using to help us organize our analysis. Labelling of speakers The researcher with whom you are in contact will let you know how to label the speakers in each recording. If it is interview data with a research participant, the interviewer will be labelled Int1, Int2, Int3, or Int4. Participants will be labelled P1, P2, P3 etc. If it is debrief data, the speakers will be labelled De1, De2, De3, or De4. Level of transcription Please transcribe the audio-recordings verbatim: that is, please transcribe every word that is spoken. If someone starts a sentence but breaks off and starts again, please transcribe every word in the false start as well as all the words in new start. We would also like you to transcribe parts of words that are spoken but not completed as when someone changes their mind about what they are going to say. Also transcribe hearable confirmations from the listening party which occur while the other person is still talking, e.g., Int2: Yeah, Int3: Mm hm, P3: Mm (see transcription examples below). Please use the correct spelling of words where at all possible. The only places to use other spellings are: (1) when a word is started but not completed, e.g., I was very up- sad (where the word upset was started but not completed); (2) where there are hesitations, e.g., I I I went home and was so u u upset. Anonymisation The researchers are ultimately responsible for making sure that all potentially identifying details are omitted from the transcripts. It would be helpful, however, if you would omit obviously identifying details such as the names of people and places in your transcript. Where you omit a potentially identifying detail please put a relevant note in that place, such as [womens name], [husbands name], [name of town], [name of organization].

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Transcription conventions Below we provide you with a list of transcription conventions that we would like you to use for features of the talk that may be of use to us in our analysis. Feature of talk Laughing Transcription convention to use Indicate in parenthesis, for example (laughing) to denote one person; (laughter) to denote several people laughing. Indicate in parenthesis, for example (coughs), (tearful voice), (sighs) etc. Flag words that are not clear by placing them in square brackets and a question mark if guessing what is said, e.g., R: At that he just [doubled? glossed?] over. [inaudible] Indicate when someones speech is broken off midsentence or mid-word by including a hyphen (-) at that point where the interruption occurs: e.g., up- not very happy (where the word upset was not completed); What do you- I dont know (where the sentence is not completed). e.g., demolish e.g., [town] Use a hyphen to indicate when one speaker overlaps with another at the transition between speakers and indicate the overlapping speech at the beginning of the interrupting speakers turn, e.g., R: He said that was impossible. I: (overlapping) Who Bob? R: No Larry.

Coughing, tearful voice etc. Unclear speech

Completely inaudible speech Word started but not completed, interruptions etc.

Strong stress on word Omitted names Overlapping speech

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