Psychotherapists’ handling of sexual attraction to clients: A grounded theory

1. Psychotherapists’ handling of sexual attraction to clients: A grounded theory Dr Anthony Arcuri1,2and Dr Doris McIlwain1 1 Department of Psychology, Macquarie University, Sydney, Australia 2 National Cannabis Prevention and Information Centre, University of New South Wales, Sydney, Australia 13th International – 2nd World Conference of the Association of Psychology and Psychiatry for Adults and Children (A.P.P.A.C.) Athens, Hellas, 20 May to 23 May 2008

2. Background • Decades of absence from psychotherapeutic discourse • In last 20 years, some progressive research: largely descriptive, sporadic, fragmented, primarily US-based • In particular, no theory • RQ: What is the process of psychotherapists’ handling of sexual attraction to clients?

3. Method – Grounded Theory • A method where data is collected via interviews and analysed qualitatively • Generator of theory “where existing theory is inappropriate, too abstracted, or absent entirely” (Henwood & Pidgeon, 2003, p. 134). • Aim is to produce an innovative theory that is ‘grounded’ in data • Achieved via a two-way process between the researcher’s conceptualisations and the raw data

4. The participants • Eleven psychologists who practice psychotherapy • Six men, five women • Mid-twenties to mid-sixties • One to 40 years’ experience • Varying theoretical orientations • Learning theory-based (CBT, DBT, ACT) • Psychodynamic – Narrative • Systemic family therapy – Humanistic • Interviewed about hypothetical experiences of sexual attraction to clients

5. The theory Sexual attraction develops Appraisal of context  manageability Decision-making  ethics, consequences Actions Consequences Resolution; End therapy

6. Development of sexual attraction to clients • Client – physical, personality, behaviour, similar in age to psychotherapist • Psychotherapist • Usual attraction to above qualities  mild experience • Unmet needs: intimacy, sexual fulfilment, excitement, validation of self-image; occasioned by relationship break-up, loneliness  more intense experience • Age: decrease of libido with age hinted at • Context of therapeutic relationship – intimate, emotionally intense

7. Handling the sexual attraction – the psychotherapist’s characteristics • Combined personal and professional identities – values, morals, ethics, boundaries, beliefs • Maturational characteristics – psychotherapy experience, age, life experiences • Psychotherapy training history • Theoretical orientation • Relationship status • Gender

8. Appraisal of the sexual attraction • Intensity – low to high • Interference with psychotherapy – minimal to great • Mutuality of the sexual attraction • The client’s characteristics – presenting problems, emotional stability, age • Timing – point during therapy at which it emerged • Reasons – self-origin, client/therapy-origin

9. Perceived manageability • Self-efficacy and self-control • Less manageable contexts: • Highly intense, greatly interfering sexual attraction • Mutual sexual attraction • Especially vulnerable clients • Previous unsuccessful attempts at handling the sexual attraction

10. Decision-making – Psychic and behavioural management • Acknowledgement and awareness • Repression and ignorance – perhaps more common among those less experienced • Allowing sexual thoughts – conflicting beliefs • Active strategies – self-analysis, self-talk, self-control/willpower, mindfulness • Passive strategies – compartmentalise, disregard, shut off the sexual attraction • Behavioural strategies

11. Therapeutic use of the sexual attraction • When sexual attraction appraised as relevant to therapy • Use it to understand client’s needs and relational style; assist treatment planning • Mixed opinions regarding self-disclosure • Unethical across all contexts • Unethical only if: client emotionally unstable, immature; sexual attraction due mainly to therapist’s issues; disclosure raw, direct

12. Self-disclosure of the sexual attraction • Might self-disclose if: • Confident • Received guidance about doing so • Sexual attraction appraised as having emerged via the process of the therapeutic relationship • Perceived as having therapeutic benefit • Direct disclosure – one participant • Indirect disclosure – concepts of transference, countertransference, intimacy, closeness, non-sexualised

13. Guidance seeking • All believed important for difficult-to-manage sexual attraction • Despite this, many potential barriers: • Anxiety, shame, embarrassment, awkwardness • Same-sex attraction • Available source of guidance unsupportive, insensitive, incompetent, responsible for therapist’s future (trainee) • Past negative experiences of seeking guidance • Perceived as indicator of weakness, maladjustment • Trainee: “underdeveloped self-esteem” • Experienced therapist: maintaining reputation as “in control”

14. Guidance seeking • Conditions conducive to seeking guidance: • Source of guidance: trustworthy, open-minded, competent; psychodynamic; initiates discussions about sexual issues; self-discloses own experiences • Psychotherapist commonly self-discloses to, has positive relationship with, source of guidance • Psychotherapist desires understanding • Sexual attraction interfering with psychotherapy, difficult to manage

15. Privileging the sexual attraction • Some disclosed examples: • Special care of physical appearance • Discussing sexual attraction evocatively with others • Sexual fantasy • Some hypothetical examples discussed: • Special treatment of clients • Extended sessions • Manipulation to meet own needs • Socialising with the client • Sexual relationship/contact

16. Discontinuation of psychotherapy • Where sexual attraction deemed unmanageable • Access to adequate referral networks • Decision in consultation with colleagues, client • How to tell client why referring them? • Genuine reason? • White lie?

17. Implications • Raise awareness of sexual attraction issues among psychotherapists and the profession • Coverage of sexual attraction issues in psychotherapy training and ethics guidelines • Education: normalising; discussed in and outside of ethics classes; modelling of appropriate behaviour, disclosure; based on sound theory and evidence • Scholars of different theoretical orientations need to articulate their positions on sexual attraction issues • Supervisors: set conditions conducive to guidance seeking

18. Limitations • Self-reported, mostly hypothetical data • Researcher influence on collection and interpretation of data • Gender • Pre-existing beliefs

19. Future directions • Many questions remain unanswered • Exploration of actual experiences • Clarification of the role of gender in the process (via quantitative research) • Further examination of the role of intensity • Clients’ experiences • Momentum

20. For further information or discussion, contact: Anthony Arcuri a.arcuri@unsw.edu.au