Simply put, sexual/romantic relationships between clients and counsellors/therapists across the spectrum of psychological helpers is seen as universally unacceptable. Despite this fact, according to recent research (Vessentini et al, 2022) over 70% of mental health professionals report emotional feelings and sexual attraction to their clients and 27% fantasized about having sexual contact with their clients, although only 3% acted on such impulses. So, in reality very few therapists had sexual relationships with clients (around 1 in 30) and when relationships did occur it would typically be with only one client. In Vessentini and colleagues work, it appears forming a friendship with a client, and especially amongst older therapists, was more common and this occurred mostly after therapy had ended. Additionally, accepting gifts was common in 8 out of 10 therapists, and 20% of therapists also reported giving goodbye hugs at the end of therapy. This would indicate that the traditional approach of psychologists as a figure who remains a ‘blank page’, keeping themselves out of the therapeutic relationship except as diagnostic interpreters, is out of date and Rogers taught the idea that the therapeutic relationship should be one that is authentic real and congruent (Worth & Proctor, 2020). That being said, therapy is focussed on the client and their issues and so the relationship is and (needs to be) somewhat one-sided. The question is more: to what extent does the therapist need to be involved in the relationship in order to form a good working alliance? and then beyond that; how to ensure the nature of this relationship does not cross boundaries into a personal and even sexual one that ultimately puts the client at risk as a result of meeting the needs of the therapist.

‘Perhaps because therapists and patients spend hours alone, during which patients share very personal feelings—feelings they may not share even with their romantic partner or most trusted friends—to which therapists attend with empathy and without judgment. Such an environment is conducive to the development of intimacy’. Psychology Today

So, the nature of a relationship where one person is listening intently and acknowledging and accepting of a client (who may be lacking exactly these qualities In their own relationships…) seems obviously appealing to the client. Let us imagine a female client working with a male counsellor and wrestling with the difficulties of living with a partner who seems disinterested, the two of them lacking connection, and the client, in effect, experiencing not being listened to or acknowledged- this could lead to an interest in pursuing a relationship with her therapist. This might be compounded if the counsellor is also in a relationship lacking connection and so on, ripe ground for the beginning of an affair… So, the difficulty is not just the client’s needs but also those of the therapist.  The counsellor’s role in this situation, however, is to take careful note of what is happening between themself and the client and use congruency to reflect back to the client, what they see is happening:

‘I notice that you are missing connection in your relationship- and part of that is your partner not listening or really acknowledging you and that my job, is to do exactly those things… and that to you, having a partner who does behave like this is what is really appealing to you…’

We need to be under no illusion that, in a space where the talk time ratio is greatly in favour of the client and our focus is intently on them, there is an appeal in the therapist and indeed, you may find if enormously appealing in your own therapists/counsellors or supervisors, as they in essence, ‘get you’. If the nature of our therapy conversations is all about living with someone who in fact does not ‘get you’, you can see the possibility of considering the therapist as a potential candidate for a partner… and also the obvious inequality in the relationship where rarely is the therapist revealed warts and all- they are arguably, whilst behaving strictly in the role of therapist, creating an unrealistic and false impression of themselves. In expert helping conversations the therapist may talk infrequently. This ‘talk-time ratio’ can often be 80:20 in favour of the client; indeed, this metric is thought to predict positive clinical outcomes (Miller and Rollnick, 2023). In light of such unequal input is it really logical that this represents the counsellors normal day to day interactions? If creates an illusion of a potentially falsely shining halo as the most listening, empathetic individual we are ever likely to meet. Equally when it comes to our own needs, these need to be met elsewhere and on more even-ground i.e., a relationship that forms between two people who have equal air space, not one where one is paid to listen and reflect whilst the other is bearing their soul.

An interesting point regarding client/patient relationships is the probable difference in gender responses, with men being more likely to cross the boundary of starting a sexual relationship with a female client than women therapists doing the same. Arash Emamzadeh, writing in Psychology Today, suggests that a) more men than women are likely to be sexually interested in clients and b) the reason that Vessentini et al’s research found more men than women being sexually interested in clients may relate to three possibilities, 1) more opportunity (most male therapists are heterosexual and most clients are female) 2) the frequency and strength of sexual desire being greater in males and/or 3) the factor of dominance or need to dominate being greater in men. Aside from Emamzadeh’s reasoning, a further factor in breaking the taboo of therapist/client relationships could be that of reactance.

A further consideration in the dynamic of therapists beginning relationships with client may relate specifically to the fact that it is not allowed- if you want to do something simply tell them they are not allowed to. This concept relates to psychological reactance (Rosenberg, el al, 2018). Psychological reactance may well feed into the dynamic of therapists forming sexual and romantic relationships with clients (Brehm 1966). Simply put, reactance is the psychological response to any actual, or perceived, curtailment of our autonomy. Ironically, if we were to take the example of a smoker in the contemplative stage for change- so they are actively hoping to change- and they then encounter a professional seeking to gain purchase on the client’s impetus and so starts by making suggestions about how/when/why the client could/should quit this in turn, may increase the likelihood of that person continuing to smoke. Essentially, we are presented with an argument which restricts our freedom (or at least threatens to) and we react by thinking of the opposite argument. How does this relate to the taboo relationship? If it is not allowed, should never be done, is contraindicated by all authorities, then it could become more attractive, and on the argument goes. This dynamic naturally feeding into individual’s reactance and the mere presence of the taboo (curtailment of freedom) promotes not having that freedom restricted.

Relationships between therapists and clients are seen, essentially, as damaging and there is, of course, an inherent imbalance of power and vulnerability on the side of the client who expose their perceived weaknesses and susceptibility. Celebrated therapist Irvin Yalom warns of the problems inherent in therapists engaging in sexual encounters with clients in Love’s Executioner. In fact, he does not differentiate between seducer and seduced, when discussing his patient Thelma (who had engaged in a sexual affair with her therapist ‘Matthew’: ‘When he seduced Thelma (or permitted himself to be seduced- same thing’). He also has no ambiguity when he states: ‘I’ve seen too many patients badly damaged by therapists using them sexually. It’s always damaging to a patient.’ (Yalom, 2012).

Joana Briscoe author of The Seduction, writes about the nature of the client therapist relationship and how it can foster sexual tension:

‘From the very act of revelation, a feeling of affinity can grow. In such safety and solace, with all the exclusive focus you could ever wish for, you start wondering about this person who sits opposite you – the therapist. This expert trained to understand the human heart. Who is this enigma, who gives clues to their personality only through their clothes, voice, décor?’

Briscoe also goes on to quote the relationship coach Jan Day who talks about the inherent abuse of power when therapists involve themselves sexually with clients:

“They’re horribly harmful. Often the therapists who are involved are so charismatic, the clients are blinded. It’s very compelling when you’re in the midst of it, but when you wake up, you realise how harmful it is. There’s not a possibility of an equal relationship: it’s always distorted, always an abuse of power. The – usually male – therapist uses their power to get what they want when they’re supposed to be serving your growth. You give a lot of trust to a therapist and if they misuse it, any good work they could have done is betrayed. It’s a mess, basically.”

Another earlier study than Vesentini et al’s work was carried out by Pope and Vetter, focussed on patients who had been sexually involved with psychotherapist and found that around 90% or patients who became sexually involved with their therapist were harmed by it, and that of these clients 14% had attempted suicide. Contrary to Vessentini et al’s work, they found roughly 7% of male and 1.5% of female mental health professionals were willing to admit to a ‘sexual-boundary violation’ (Pope and Vetter, 1991).

So, what is the obvious course of action when faced with a moral dilemma relating to a relationship with a client? The guidance from all governing bodies across nations Is clear it absolutely cannot happen. When there is risk, the obvious first line of call would be your supervisor who can shed light help you work through the issues. Also, have consideration of the nature of how a counselling relationship looks from the outside, i.e., to what extent is your relationship a revelation of the authentic self? How realistic would this therapeutic relationship translated into the ‘real-world’ relationship you may be considering embarking on. The data on how these relationships are damaging, even increasing risk of suicide for one clear, stark example should serve as warning for any such transgressions. Reactance and the allure of the taboo are real phenomena, but psychological helpers need sufficient training and preparation to be equal to the task of keeping personal relationships personal and therapeutic one’s real and honest yet entirely professional.

References

  1. Brehm, J. W. (1966). A theory of psychological reactance. Oxford, England: Academic Press.
  2. Briscoe, J What happens when your relationship with a therapist turns into an affair? | Life and style | The Guardian Last accessed November 2023.
  3. Emamzadeh A, What Happens When a Therapist Is Attracted to a Client | Psychology Today Australia last Accessed November 2023
  4. Miller, W. R., & Rollnick, S. (2023). Motivational interviewing: Helping people change and grow. Guilford Publications.
  5. Pope, K. S., & Vetter, V. A. (1991). Prior therapist-patient sexual involvement among patients seen by psychologists. Psychotherapy: Theory, Research, Practice, Training, 28(3), 429.
  6. Rosenberg, B. D., & Siegel, J. T. (2018). A 50-year review of psychological reactance theory: Do not read this article. Motivation Science, 4(4), 281.
  7. Vesentini, L., Van Overmeire, R., Matthys, F., De Wachter, D., Van Puyenbroeck, H., & Bilsen, J. (2022). Intimacy in psychotherapy: An exploratory survey among therapists. Archives of Sexual Behavior, 1-11.
  8. Worth, P., & Proctor, C. (2020). Congruence/Incongruence (Rogers). Encyclopedia of personality and individual differences, 838-840.
  9. Yalom, I. D. (2012). Love’s executioner: & other tales of psychotherapy. Basic Books.