by Richard Irons, MD
For medicine may be regarded generally as the knowledge of the loves and desires of the body and how to satisfy them or not; and the best physician is he who is ab1e to separate fair love from foul, or to convert one into the other.
--Eryximachus in Plato’s Symposium
The healing potential in the professional‑patient relationship is facilitated by inherent disparity in position, education, and power. Yet, since its origin in prehistory, the healing profession has been shadowed by abuse of privilege. Sexual misconduct and offense are among the most common and egregious forms of abuse. Standards of conduct and ethical codes have been established to define ideals, expectations, and boundaries for healthcare professionals. They sometimes fail to remain godlike and perfect in their discharge of duties, despite being held to these higher moral and ethical standards. For they are human and subject to the same maladies and shortcomings as the patients they serve.
Healthcare professionals may or may not have multiple domains in which their sexual addiction is acted out. Some professionals are able to successfully compartmentalize their addiction, expressing it only outside professional practice or a committed relationship or only on the Internet. Although this compartmentalization is probably incomplete, the rules established by the narcissistic professional addict may preclude acting out within certain relationships because of the risk of significant harm and consequences for both the professional and the person under his or her care. Most sex addicts try to maintain the illusion of control by setting limits on their sexual fantasy or behavior. All healthcare professionals have been trained to use delayed gratification of their own desires and to establish interpersonal boundaries with patients in order to serve as a professional in the service of patients. The large majority of sexually addicted healthcare professionals in whom addiction was initially established before or outside of the professional workplace will try to maintain this limit until the late stages of their disease.
Each patient who comes to a healthcare professional seeking help, relief, cure, or healing attempts to garner sufficient belief and trust in the professional, to implement the instructions and counsel given. Courage and faith permit the patient to surrender to the healing process beyond the boundaries of logic and sensibility.
The experience of seduction in a professional-patient relationship by either person takes on direct and immediate importance when events occurring between a professional and patient lead to an allegation or formal complaint of professional sexual misconduct or offense. I have served as medical director of assessment programs that have formally evaluated more than 350 physicians, clergy, and lawyers who have been accused of such improprieties. Professional sexual misconduct and professional sexual offense present with a wide and diverse array of scenarios, as outlined in Table 1. To precisely define the type and severity of professional impropriety, and to make accurate and appropriate diagnoses, it is important to gather as much information as possible about the events leading to assessment, including the specific nature of the thoughts, feelings, and actions that occurred between the physician and the complainant. A statement of the complainant(s) description of events is crucial and should be obtained prior to beginning any evaluation or investigators. A sexually exploitive professional may utilize more than one scenario, or may use variations on a given theme. The behavior in question is often ritualized, and frequently compulsive in nature. Once an assessment team has been able to compare the physician’s version of events with that of the complainant, it becomes possible in most cases to construct probable scenarios and to begin to establish a causal hypothesis on how and why impropriety may have occurred.
Table 1: Common Sexual Impropriety Scenarios
· Therapeutic touch becomes erotic or is experienced by patient as sexual
· Caretaking or emotional support extends beyond professional boundaries
· Romantic enmeshment with patient or coworker
· Use of power and position to advance sexual agendas
· Fatal Attraction enactment of rescue fantasy
· Paternal or maternal nurturance of a patient
· Involvement with family member of patient
· Medical frotteurism, voyeurism, or exhibitionism
· Unnecessary or overextensive genital examination
· Rude/abusive/insensitive/verbally inappropriate solicitation
· Surgeon offering sexually enhancing procedures or offering sexual therapy for a patient’s sexual or relationship problems
· Cultural dissonance between physician and patient becomes sexualized
· Molestation of patient who is physically, mentally, or emotionally unable to offer resistance or is under the influence of mood altering substances
· Attempt by physician to resolve conflicts involving sexual preference
· Unconscious reenactment of incestuous desires or past sexual abuse
Professional sexual improprieties can generally be classified into one of three major categories: paraphilia, sexual disorder Not Otherwise Specified (NOS ), or work-related problems. The essential features of a paraphilia as defined in the DSM-IV-TR (American Psychiatric Association, 2000) involve recurrent, intense, sexually arousing fantasies, sexual urges, or behaviors generally involving 1) nonhuman objects, 2) the suffering or humiliation of oneself or one’s partner, or 3) children or other nonconsenting persons that occur over a period of at least six months. The diagnosis is made if the behavior, urges, or fantasies cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (DSM-IV-TR, p. 566). A sexual disorder NOS is defined as “a sexual disturbance that does not meet the criteria for any specific sexual disorder and is neither a sexual dysfunction nor a paraphilia. Examples include a) marked feelings of inadequacy concerning sexual performance or other traits related to self-imposed standards of masculinity or femininity, b) distress about a pattern of repeated sexual relationships involving a succession of lovers who are experienced by the individual only as things to be used, and 3) persistent and marked distress about sexual orientation (DSM-IV-TR, p. 582). Sexually addicted healthcare professionals often fall into one of these two diagnostic categories. When the behavior and/or scenario do not easily fit into either category, and is not considered a direct symptom or manifestation of some other DSM-IV-TR Axis I diagnosis, then we have utilized the work-related problem (V62.2) descriptor for such professional sexual misconduct.
A more complete listing of possible Axis 1 diagnoses associated with professional sexual misconduct or offense is presented in Table 2. Our assessment team members have found it helpful to complete the differential diagnosis on Axis I before considering Axes II and III. Psychosexual disorders and paraphilias, when identified, should be described as precisely as possible. If the NOS category is utilized, then it is important to use appropriate descriptors that define the features seen. In our program the most frequent features noted, in addition to specific paraphiliac behaviors, are those of addiction, exploitation, voyeurism, predation, romance, and assault. The severity of the disorder, its duration, the current level of activity, and its amenability to treatment should also be defined to the greatest extent possible. Many cases involving professional sexual impropriety are associated with and at least partially attributable to characterologic pathology.
Table 2: Possible DSM-IV TR Diagnoses Associated with Sexual Misconduct Other Than Sexual Disorders
· Organic Mental Disorder
· Erotomanic Delusional Disorder
· Bipolar Affective Disorder
· Obsessive Compulsive Disorder
· Atypical Dissociative Disorder
· Impulse Control Disorder
· Adjustment Disorder (with disturbance of conduct)
Intervention is the first action step in resolving allegations of professional sexual impropriety or misconduct. A successful intervention requires complete honesty and compassion on the part of those who are confronting the potentially impaired professional. A straightforward presentation of the allegation is almost always the best approach. Expression of concern on the part of concerned parties and authority figures who are present can help keep the accused from slipping into morbid despair and possible suicidal ideation or action while nevertheless making it readily apparent that sexual harassment, abuse, and offense are intolerable and unacceptable. A good intervention reflects social justice by making the perpetrator of sexual exploitation accountable for the behavior and assuring the victim(s) that there will be no further misconduct. Experience suggests that professionals alleged to have engaged in sexual impropriety referred for formal assessments are a diverse, predominantly male population, who will commonly have one or more of a wide array of diagnosable illnesses. Although specialized professional assessment programs have found that many of these professionals have sexual disorders, significant numbers were found to have undiagnosed mental disorders. Some present with active substance dependency, acute mental illness, or acute psychiatric illness. The majority of these professionals can be helped, and it is possible for carefully selected professionals to re-enter professional life at some time in the future with supervision and under carefully drafted and monitored recovery contracts.
Some will apply the philosophy of determinism to professional sexual misconduct. Others will consign offenders to exile as examples for the public to see the wages of moral turpitude. Many will divide the lot into those that are sick and those who are bad [like the character Dr. Hannibal the Cannibal Lector in the film Silence of the Lambs]. Through our choices we will push professionals accused of sexual misconduct toward the medical model (assessment and treatment with potential rehabilitation) or toward the legal model wherein they seek justice and a legal remedy to the allegations made against them. Whenever possible, professions dedicated to offering help and healing to others should extend the same services to peers who have encountered and experienced this occupational hazard. Table 3 outlines a general protocol that can be used to address allegations of professional sexual misconduct. Although treatment and therapy are often prolonged, many professionals experience personal healing and significant life transformation, especially when it is supported and encouraged. However, professional rehabilitation is possible for some but not all of those professionals who have been able to attain personal growth and genuine change. In the hundreds of sexually exploitive professionals that I have assessed, treated, or known, only slightly more than one-half of them have returned to their former professional practice, and the mean time between intervention and professional reentry is about eighteen months.
Table 3: One Protocol for Confronting Allegations of Professional Sexual Impropriety
1) Allegations of professional sexual misconduct should be carefully documented and serve as precipitating events in a peer review and/or licensure board investigatory process.
2) When sufficient collateral information has been accumulated, then an independent multidisciplinary assessment by a team of experienced professionals is often useful if the accused physician is cooperative.
3) If the accused professional is not willing to undergo independent assessment, then the concerned parties must decide whether due process or emergency action with due process is appropriate.
Sexually inappropriate behavior by a professional involving a patient is illegal as well as unethical. Professionals who engage in professional sexual misconduct are probably in violation of the state or provincial laws under which they are permitted to practice. Some professionals who have committed professional sexual offenses may be recurrent perpetrators. In some instances sexual exploitation will be reported to a professional board by a subsequent treating physician or other therapist. It is generally perceived that licensure board actions are too infrequent and too mild, but without timely reporting by victims and substantive information from other health care providers, such cases continue to be very difficult to substantiate to the point that definitive licensure board action can be taken. In at least fifteen of the fifty U.S. states, there are specific criminal laws that define professional sexual misconduct as a specific felony. Professionals who engage in predatory patterns of sexual exploitation do serve prison terms.
Victims who are able to overcome the trauma and pain associated with sexual abuse may become empowered sufficiently to initiate and engage in criminal, civil, or administrative law [professional licensure board] actions that result in other types of restitution as well as revocation of professional licensure. In most cases, victims do so because they wish to bring justice to the abusers of power. Legal actions may require the victim to describe the specific behaviors involved on multiple occasions and in public, which is often painful and traumatic. Witnesses often are understandably reluctant to testify, which complicates appropriate prosecution. However, recurrent interludes of misconduct with numerous patients will likely result in much more punitive action, including revocation of licensure.
The professional entering an assessment becomes a patient, and is requested to set aside the professional role and its attendant defensive armor. An assessment is usually a short-term residential or day process of three to five days that provides independent, objective, multi-disciplinary assessment for possible mental illness and professional impairment. The assessment model presented here is based on twelve years of experience evaluating sexually exploitive professionals. It was developed in response to the need expressed by licensure boards, regulatory agencies, professional organizations, and the public for an objective forum in which allegations of sexual harassment, professional sexual misconduct, and professional sexual offense could be explored and considered independently from treatment, therapy, administrative due process, civil suits, and criminal legal proceedings. The crucial objective for the assessment team is to establish a causal hypothesis that helps explain the vulnerability of the victim(s), and the behavior of the accused professional. The ability to formulate such a hypothesis requires elaboration of the reality between the victim(s), peers, and the professional’s versions of events leading to the formal complaint(s). The degree to which this hypothesis can reconcile disparities in the multiple accounts of the events determines to a large measure the value, acceptance, and utility of the assessment conclusions and recommendations.
It is important to reiterate whenever necessary that the assessment is not a trial and that the team members are not being asked to sit as judges or jurors. Assessments are not intended to substitute for the finding of facts and adjudication inherent in legal proceedings, but rather as an alternative or supplementary means by which an impartial inquiry into the physical and mental health of the accused professional may be conducted. Possible personal vulnerabilities, mitigating as well as aggravating factors, cognitive distortions, and errors in judgment that may have substantially contributed to the allegations brought forward can be considered within the medical model. Diagnoses and recommendations made by team consensus during clinical staffing may be accepted and implemented as deemed appropriate by all concerned parties. Using this model, the team can agree about 95% of the time on conclusions and opinions regarding:
· professional impairment or potential impairment
· diagnoses based on DSM criterion
· recommended courses of action
· whether professional rehabilitation appears feasible and realistic
· the ability of the professional to practice medicine under supervision and with corrective action while maintaining and protecting public safety at present or in the foreseeable future.
When the factual disparity between the complainant’s and the professional patient’s versions of events remains too great, then the assessment team should not advance a causal hypothesis, but instead should report the assessment as inconclusive and recommend that the matter be forwarded into formal legal process (Irons, 1994).
The assessment model described is comprehensive but often very expensive. It has some other significant limitations as well. There is no uniform or standard nomenclature or definition of professional sexual impropriety, and standards vary from profession to profession and from one assessment team to another. Assessment professionals are often requested to do a comprehensive evaluation without a team of evaluators, or will find that the only way they can complete an assessment requires component evaluations to be done independently and without the opportunity to arrive at conclusions and opinions by consensus. The expectations from an assessment and the type chosen commonly depend on the concerned party that has confronted the individual. Regulatory agencies (e.g., hospitals, managed care organizations, state or provincial licensure boards) will have a different perspective and agenda than professional organizations or employers. And finally, individuals and organizations that do evaluation as a initial part of the treatment process have an inherent conflict of interest even if they offer other treatment alternatives, as most patients (including professional patients) will find it difficult if not impossible to choose an alternative. There is an inherent tendency to diagnose what you know and can treat.
In our published, peer-reviewed study (Irons & Schneider, 1994) of 137 consecutive healthcare professionals referred for a formal multidisciplinary assessment of alleged professional sexual offense, 93% of the professionals were found to have work-related problems related to sexual conduct. At least 66% acknowledged sexual exploitation in their professional practice, and in 27% such exploitation was not found to be present, based on the information available. In 7% of the cases, the professional denied exploitation although collateral information was believed to be credible; therefore the assessment results were deemed inconclusive. It is of interest that 65% of these professionals were diagnosed with a sexual disorder, usually a paraphilia, while 30% did not meet diagnostic criteria. Even so, 86% of this sub-population of 41 professionals without a defined sexual disorder was still believed to have work problems related to their sexual conduct. In the entire sample of 137, 58% were determined to be professionally impaired at the time, and 10% were found to be potentially impaired. We recommended inpatient treatment for 49% of these professionals, and outpatient treatment for another 43%. No treatment was recommended for only 2% (3) of our study population. These three professionals presented with allegations that the assessment team believed were either false or grossly exaggerated. In ten cases (7%), treatment recommendations could not be made because assessment results were inconclusive. Of the 88 patients in our study diagnosed with a sexual disorder, 73% were defined as sexually exploitive in their professional practice, 87% had work-related complications, and 85% were found to have addictive features associated with their disorder. Thirty-eight percent (33) were diagnosed with chemical dependency.
The lack of standard protocols for assessments, the problems with maintaining consistency even within a dedicated assessment program, and the reasons for conducting the assessment (e.g., punishment, rehabilitation, defense against a malpractice claim, or a last chance to reconcile a marriage when the spouse discovers she has been betrayed) make comparison of assessments from different providers difficult. Professionals with more financial and professional assets to lose are more likely to get sophisticated evaluations in contrast to those who have leaner resources or who engage in limited or general professional practice.
Historically, most of the treatment provided for professionals who engaged in sexual violations was given through individual psychotherapy, or as an adjunct to treatment for either a substance-related disorder or some other DSM Axis I disorder. A major area of controversy, as well as a conundrum to research that workers in this area have experienced, is in defining when an Axis I mental disorder (with or without Axis III medical conditions) has contributed significantly enough to be considered a mitigating cause for the sexual offense(s). Skeptics are eager to suggest that those facing consequences for sexual exploitation wish to flee into illness or addiction to avoid taking personal responsibility for engaging in unprofessional conduct. Some academic nimrods would rather wash their hands of the whole mess by concluding that most professional boundary violations (and particularly serial patterns of sexual misconduct) are a manifestation of characterologic pathology, and will be found to be part of an unsavory personality disorder.
Often, initial treatment for professionals who are evaluated and found to have sexual disorders and/or other mental disorders associated with professional sexual misconduct begins at residential sites or by using day intensive programs that adhere to one of the following models. Each model has its own strengths, weaknesses, limitations, and biases.
Cognitive/Behavioral [including community offender treatment]
Gene Abel, at the Institute for Behavioral Medicine in Atlanta, Georgia, has extensive experience in cognitive/behavioral treatment over more than twenty years of work. Two methods appear to be especially helpful for disrupting the cognitive distortions of professionals involved in sexual misconduct. First, in a group setting, members are able to confront and challenge the irrationality or rationalization within each other’s justifications and beliefs. A second method is to have the professional perpetrator write a letter to one of his victims explaining in detail all the ways the professional groomed and manipulated the patient-victim to encourage and seduce the patient into sexual activity. Such letters should never be mailed to the patient-victim, of course. Abel and colleagues focus on developing skills to decrease arousal, including the development of safeguards to attempt to prevent the professional from ending up in a high-risk situation again, paralleling the authors’ work with other types of sex offenders but extending it considerably (Abel, Osborn, & Warberg, 1995). Abel believes that professional sexual misconduct have features in common with paraphilia, and that about 20% of sexually exploitive physicians in his treatment program have an actual paraphilia that extends into their medical practice, usually manifested as exhibitionism, voyeurism, frottage, or rape (Abel & Osborn, 1999). Psychophysiologic measures such as the penile plethysmograph, and the use of the polygraph (lie detector) may be utilized in diagnosis or evaluation of treatment outcomes.
Typically, a period of evaluation and intensive treatment is followed by a structured aftercare program, including cognitive-behavioral therapy, re-education, and a strong emphasis on relapse prevention. Examples of reentry plans and procedures are available in the literature. (Abel & Osborn, 1999; Abel, Osborn, & Warberg, 1995; Schoener et al., 1989). Abel states that of the physicians referred to his treatment program, 52% have returned to practice. Of the 48% who have not returned to practice, nearly two thirds were removed from practice by their medical board or as a result of criminal action. The number of patients victimized, the sex of the victims, and the extent of sexual involvement (voyeurism, frotteurism, frottage, oral or anal sex, intercourse, or extensive affairs) are not major factors in determining the acceptability of a physician returning to practice. Instead, assuming successful completion of treatment, it is primarily the ability to establish a practice plan that protects the public that determines the viability of professional reentry (Abel & Osborn, 1999).
Table 4: Cognitive Behavioral Components of Treatment for Professional Sexual Misconduct
A. Cognitive-Behavioral Therapy
§ Identification and disruption of chain of events leading to sexual misconduct
§ Identification and correction of cognitive distortions supporting sexual misconduct
§ Building victim empathy
§ Behavior therapy techniques to decrease paraphilic interests
B. Treatment to resolve emotional conflicts contributing to sexual misconduct
§ Psychotherapy to treat chronic anxiety, depression, anger, stress, or personality disorders
§ Skills training top correct assertive and social skills deficits
§ Bibliotherapy
§ Required writing of a referenced paper in the relationship of his or her emotional problems to sexual misconduct
C. Methods to ensure patient protection
§ Practice style alterations
§ Physical layout of medical workplace to allow monitoring
§ Specific patient education and protection
§ Staff and colleague surveillance systems
§ Polygraphs
(Adapted from Abel & Osborn, 1999)
Addiction Model
In our previous study of consecutive professionals presenting for assessment with allegations of professional sexual misconduct, more than half of those evaluated met the DSM criteria for addictive sexual disorders and/or active substance dependency (Irons & Schneider, 1994). Many sexually exploitive healthcare professionals have derived great and lasting benefits from completion of a formal addiction treatment program. Although some residential treatment providers have claimed high recovery rates for professionals with primary substance dependency, there exist few, if any, large-scale controlled studies. The treatment recovery rates reported are usually either directly compiled by the treatment center marketing department, or by a research organization the center contracts to do the work. Few studies have used prospective study methodology. Many rely on responses without objective corroboration and do not take into account patients who did not complete treatment or who were administratively discharged. In some treatment centers, the psychoeducational part of the treatment program and the group therapy component contain patients with different types of substance-related disorders and/or addictive sexual disorders and will at times have patients who are victims of professional sexual misconduct. This approach has the tendency to treat sexual boundary violations as secondary to the substance or sexual addiction. The profound impact of professional sexual boundary violations on victims and their families, and the cognitive distortions professionals have acquired, may not be addressed during primary treatment, when the emphasis is on abstinence and powerlessness over mood-altering behavior. Developmental and dynamic themes of individual patients may often not be fully explored or developed, especially if the patient is not comfortable sharing past abusive or traumatic shame-bound events in therapy groups. In the past decade, more sophisticated treatment providers began utilizing competency-based individualized treatment plans, which do provide both structure and a theoretic base that most patients can understand and apply.
Analytical/Dynamic
When professional sexual boundary violations are believed to primarily represent a manifestation of preexisting characterologic pathology, long-term insight-oriented dynamic individual therapy is often recommended. This approach is particularly suited to patients who are considered psychologically minded, meaning they have the capacity for introspection and development of insight. The goals and objectives of such therapy are often vaguely or inconsistently defined and deemed accomplished. Therapy is traditionally based on the professional patient’s perceptions, with little or limited emphasis placed on comparing those with the victim’s perceptions or depositions available from concerned parties or agencies. The latter groups may influence the initial goals of therapy, but seldom are able to monitor therapy effectively or provide their input on adjustment of goals or completion of primary treatment.
Despite more than one hundred years of experience using this approach, it remains difficult to determine the effectiveness of therapy, because controlled studies would be extremely difficult if not impossible to construct. The variation in treatment between practitioners, as well as the variation an individual practitioner may exhibit in treating different patients, is very difficult to define and quantify. Dr. Glen Gabbard (1994) has acquired extensive clinical experience with professional sexual boundary violations in his years at The Menninger Clinic in Topeka, Kansas. He uses a typology of professional sexual misconduct in which professionals fall into one of four groups with a roughly ascending order of frequency: a) professionals who are lovesick; b) professionals captivated by a romanticized masochistic surrender [giving in” to a challenging or difficult client, hoping to mollify the client by being flexible with boundaries]; c) predatory psychopathy and paraphilias; and d) psychotic disorders. Within the romanticized and especially the lovesick category, he has accumulated a significant number of professional patients whom he has evaluated and treated that includes professionals with masochistic and self-destructive tendencies who passively allow clients to intimidate or control them. He believes delving into issues or dynamics that are acted out through the sexual misconduct in depth over time leads to healing and transformation.
Some of the more common and significant themes addressed in such dynamic therapy include:
§ Unconscious reenactment of incestuous longings
§ Wishes for maternal nurturance misperceived as sexual attraction
§ Enactment of rescue fantasies on the stage of one’s professional life
§ Lonely patient perceived as idealized version of self or transformational object
§ Confusion of therapist’s needs with patient’s needs
§ Repression of rage at patient’s successful thwarting of therapeutic efforts
§ Patient’s anger at organization, institute, or authority
§ Manic defense against mourning and grief at termination
§ Conflicts regarding sexual identity or orientation
Gabbard has written an analytic yet lucid book describing ways love and hate are replicated to some extent in the analytic setting through the externalization of internal object relations. Of course, the analytic situation is intended to be the stage for the analysand’s externalization of object relations and not the analyst’s (Gabbard 1999). The principles he deftly expounds on loving relationships and romantic space are based on "the dialectical relationship and tension between the paranoid-schizoid and depressive modes of experiencing, with the ever-present potential to collapse in one direction or the other." He subdivides transference hate into two broad categories analogous to the distinction between erotic and erotized transference (Gabbard 1991b). "In the more benign variety, the patient recognizes that the hate is in part internally derived and therefore requires analysis. The hateful feelings are ego dystonic, so the patient maintains a therapeutic alliance with the analyst in pursuit of understanding the feelings rather than acting on them. In the malignant variant, the "as if " quality of the feeling disappears, and the patient views the analyst not as a figure similar to someone from the patient’s past, but rather as a truly malevolent individual deserving of hatred, identical in that sense to the original object. Analytic space collapses so that the patient is operating in a world that seriously compromises the therapeutic alliance" (Gabbard 1999). Professionals are often conflicted about the acknowledgment of anger, let alone hate. In rich commentaries over the years on physicians’ internal dynamics, George Valiant reminds us that reaction formation is a pervasive form of defense and an expression of the resentment professionals feel when their labors in the service of others are not appreciated.
In my opinion, an eclectic combination of these models tailored to the needs and psychopathology of the professional being treated provides the optimal treatment and therapy necessary for personal healing and professional rehabilitation. Anger, based on resentment, bitterness, and hatred acted out through professional sexual misconduct, inflicts destructive consequences on many others beyond the perpetrator and primary victim(s). Commonly, the destructive anger harbored by professionals in treatment bears the mark of either resentment or envy. This caustic poison acts itself out through attacking, judgmental thoughts and unconscious vindictive actions against themselves and others. The atonement of such anger is found in the exploitive professionals’ determination to seek the roots of their own rage and past trauma. Through abreaction and insight, empathy for their victims can be found. Months or years later, another form of restitution may be possible. The offending professional might have the opportunity to accept and appreciate the need for those harmed to express their anger, indignation, and outrage without hiding behind intellectual defenses and rationalizations. When able to access the courage to endure confrontation of this poisonous anger, the wounded professional may discover that the anger is derived from an arrogant inflation of perceived duty (within their professional persona). Anger and self-pity can arise from witnessing innocent suffering or the experience of emotional, litigation-based, intellectual, or physical trauma in the course of professional service. At this juncture, true and genuine personal restitution is possible. (Irons & Roberts, 1995).
Controlled studies that can look at these treatment models and compare their efficacy are needed. In the future it may be possible to assign professional patients to various subsets with specific type(s) of professional sexual misconduct and congruent personal psychopathology, then differentiate the effectiveness of each treatment model for that specific subset.
Following intervention and initial treatment, professional boundary violators who have not engaged in "egregious" professional sexual misconduct customarily will expect to return to work even if they have not completed a full course of treatment or therapy. With a continuing trend toward criminalization of professional-patient sexual violations, many of these professionals and their legal advocates are becoming less concerned with early professional reentry. There is increasing recognition of the fact that through evaluation, primary treatment and continuing progress toward the achievement of personal recovery goals, such professionals may be able to take genuine responsibility for their unethical and/or unprofessional conduct, offer restitution, and demonstrate rehabilitation potential. It is difficult to predict how long a sexually exploitive professional may have to withdraw from practice when treatment is in the early stages. Professionals in treatment often feel that their inability to remain gainfully employed and the uncertainty about whether they may return to their previous practice only adds to their burden of guilt and shame. The expense of treatment increases the degree of negative cash flow and can make it difficult to concentrate on recovery, especially when accompanied by a fear of losing family and financial stability. Fortunately, many professionals have disability insurance, business overhead insurance, or other buffers against such adversity. In the past decade, it has become more difficult for professionals in treatment to maintain their long-term disability claims, especially if they have lost professional licensure. Professionals in treatment need honest responses to their questions regarding the length of expected treatment prior to gaining the opportunity to return to professional practice. Before it is possible to make a balanced and realistic determination of professional rehabilitation potential, documented progress on a number of fronts must be attained. Table 5 outlines common prerequisites a professional should have before return to work can be safely and reasonably considered.
Table 5: Prerequisites for Professional Reentry
1) Successful completion of primary treatment, as defined by the treatment program and also by concerned parties.
2) Records from initial evaluation and treatment, which define the nature of the professional’s sexual disorder and any other addictive disease, psychiatric disorders, or medical problems known to be present and plans for continuing care.
3) Assurance by the treatment team that they believe, to the best of their knowledge, that the professional is able to practice his or her profession with reasonable skill and safety.
Definition by the treatment team, regulatory bodies (when appropriate) and other concerned parties of specific boundaries within which the professional will be able to practice.
The time any professional may need to complete these prerequisites varies considerably. In my fifteen years of experience, I have found that six to twelve months is not uncommon, and the mean time is probably greater than a year. As a result, many professionals must find non-clinical or non-professional work during this uncertain period until rehabilitation is complete, and it is possible to determine if professional reentry is feasible. Successful and effective treatment almost always requires at least some intensive group therapy within a therapeutic milieu. Self‑diagnosis and self‑disclosure are extremely important passages in the recovery process, albeit painful and difficult experiences for the professional who has exploited his or her patients (clients) and who feels guilt and shame about past personal and professional behavior. The task of acknowledging one’s lack of control over the sexual behavior and the acquisition of a strong desire to heal, change, and grow are critical passages in the treatment process. Many professionals are able to return to a monitored practice, but the timing of the return must be carefully staged in the therapeutic process. In most states, relapse will lead to the loss of licensure and destroy hope of future return to professional status.
In some situations, especially when the completion of these prerequisites exceeds two years, a comprehensive re-assessment by an objective team (or therapist) skilled in the management of professionals seeking professional reentry can be extremely helpful. In such a process, the assessment team should review treatment and therapy, confirm the working diagnostic impressions and treatment plans, and recommend practical steps the professional can take to professional reentry, professional rehabilitation, or vocational counseling that will help the healthcare professional transition into a non-clinical career.
In the arena of professional sexual boundary violations that include workplace sexual harassment, it is becoming increasingly clear that there is little if any tolerance for even minor levels of recidivism. Furthermore, there will be increasing resistance to any professional admitting to sexual harassment due to the severe potential consequences incorporated into federal employment laws. The use of chaperons or workplace monitors is commonly utilized, but has limitations as a deterrent against either professional sexual misconduct or sexual harassment. For healthcare professionals who engage in direct patient contact, it is crucial for them to recognize that any patient encounter can evoke transference and /or countertransference. In the early stages of professional reentry, limited trust and credibility, uncertainty, and even misunderstandings regarding boundaries or behavioral intent will have the potential of adversely influencing the fragile conditions under which the professional is permitted to resume professional practice. If chaperons do offer only limited protection of public safety, they at least reduce the risk of groundless allegations against a vulnerable re-entering practitioner. This is why the use of a comprehensive and closely monitored professional rehabilitation/reentry contract is so important.
At this juncture, it is then possible to draft a suitable contingency contract specific enough to be useful in promoting continuing recovery. Prerequisites will vary from situation to situation and will need to be agreed on by all concerned parties. Concerned parties may include the employer, the professional’s partners or business, the hospital in which the professional has practice privileges, or a state professional health or rehabilitation program. Any of the concerned parties may serve as the "contracting program" as the term is used herein. If a professional licensing board is involved, its input and cooperation is crucial for this reentry tool to be effective.
The following fifteen contractual elements have been found to be of value in drafting a contract for the returning professional (Irons, 1992). Each should be considered for inclusion individually, for all may not apply to a given situation.
For many behavioral boundary violations, attempts at behavioral modification and verbal or written warnings to address questionable behavior have been issued before. The goals now are to provide a mechanism for protection of the professional patient relationship, to allow restoration of credibility and trust, and to promote corrective action. Recovering sexually exploitive professionals who return to their community and their practice present a model of healing that can instill hope and optimism in others struggling with this addiction, their co‑dependents, and the victims of this devastating disorder.
1) The professional acknowledges pain and suffering from a specific sexual disorder and attendant defects of character and agrees to abstain from certain specific behaviors in personal and professional life.
2) The professional establishes and defines a recovery network. Persons within this network may include family members, significant others, trusted friends, mentors, sponsors, and individuals from the professional’s workplace. The recovery network may meet initially and as needed to ensure that all participants understand the terms of the contract and the established boundaries.
3) The professional agrees to continue in treatment with a therapist experienced in treatment of the sexual disorder and any other relevant mental disorders that is also acceptable to the directors of the contracting program or concerned parties. Both individual and group therapy should be considered. Regular, timely written reports (at least quarterly) should be provided to the contracting program or to a mental health professional who provides “oversight’ of the clinical progress and who makes such reports to the contracting program and necessary concerned parties.
4) The professional identifies a primary care physician who is experienced and informed about the treatment of addictions and sexually transmitted diseases, including AIDS. The designated physician will see the professional for medical review on a regular basis and will agree to be part of the individual’s recovery network.
5) The recovering professional agrees to respect, defend, and uphold specific practice boundaries established and supported by all concerned parties. These boundaries should be defined in this clause as precisely as possible.
6) The professional agrees to a precise and regular monitoring of practice boundaries through an established regular procedure. This may include:
a) The use of a professional "clinical associate" for a professional‑patient (client) interaction
b) Regular practice review by a peer professional
c) Random patient chart reviews
d) The use of patient satisfaction surveys, which are reviewed by the practice monitor
e) Regular reports by the designated practice monitor, usually a professional peer, to the contracting program and concerned parties at specified intervals
7) The professional agrees to provide body fluid samples on request for the purpose of determining the presence of any mood‑altering substances, including alcohol. If the individual has a history of substance abuse or dependency, testing should be done on a random basis. If no such history exists, then testing should be done if there is reasonable cause to suspect substance use that may directly or indirectly be affecting professional performance.
8) The professional agrees to monitoring of compliance with prescribed psychotropic medication if determined necessary, with reports forwarded to the contracting program.
9) When appropriate for inclusion in the contract, there may be a provision in which the recovering professional agrees to participate actively in a twelve‑step program for sexual addiction recovery that promotes only healthy non‑sexual relationships among group members.
10) The professional may also agree to encourage and support both treatment and twelve‑step program participation for family members and others with whom the professional has continuing social contact.
11) The professional agrees to complete professional education, or specific courses on professional boundaries, ethics, interpersonal communication, or anger management, if requested.
12) The professional agrees that the terms of this contract, and especially the professional practice boundaries, will be disclosed to others, including patients (clients) on a "need to know" basis. This provision needs to carefully and precisely define who needs to know and what they need to know.
13) The contracting program, members of the recovery network, and concerned parties outline their obligation to report sexual offenses, professional impairment, and sexual misconduct as defined by state law. Professional impairment, professional misconduct, and violations of this contract will be reported to the state licensing board as required by state law and by any stipulated agreement the professional may have with their licensing board. It is recommended that copies of these specific laws be provided to the recovering professional. The signed agreement needs to state that violations will be promptly reported.
14) The contracting program agrees to provide advocacy and continuing support for the professional. The program will regularly review the professional’s progress in recovery and compliance with the provision of this contract. It will provide timely written reports to regulatory bodies and agencies that require them.
15) The professional agrees to continue participation in this recovery program for a defined period of time with annual review of contract terms.
A contract so constructed defines boundaries of acceptable personal and professional behavior. It provides a mechanism by which a professional can take responsibility for his or her conduct while participating in a state professionals’ program that provides a support system for complying with contractual requirements. The success or failure of the contract depends on the effectiveness of the monitoring provision. It is essential that there is a clear statement of the consequences for violating the contract provision that sends a clear message to the professional that the responsibility for maintaining compliance lies with them and not with the supporting professional program.
The provision determining disclosure of the terms of the contract (on a "need to know" basis) will vary from state to state and from situation to situation, but the policy is a critical feature of the agreement. Professionals in early recovery find disclosure difficult to accept because it potentially can result in discredit and rejection. Disclosure protects all involved parties‑‑the professional’s patient (or clients), the public, the advocates for the professional, and even the recovering professional to themselves. Resistance to this disclosure provision‑‑or attempts to minimize it--provides some evidence of how well the professional is handling the reentry process. Ongoing group therapy with other recovering professionals helps the individual deal with the powerful emotions that inevitably arise during implementation of contract terms. The spirit with which the professional accepts and facilitates monitoring will also vary. It is hoped that this set of recovery contract provisions for professionals will assist those who address the complex and challenging problems of sexual and characterologic disorders in this population. Continued growth in our understanding of the nature of sexual exploitation and further knowledge about treatment approaches and continuing care will help us rehabilitate professionals who truly are unable to help themselves. They have much to teach us if we are willing to listen and learn.
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