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Section 15
Ethical Issues in Therapy: Therapist Self-Disclosure of Sexual Feelings

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The deleterious effects of therapist–client sexual relations have been known for some time; negative consequences for the client can range from early termination of therapy to worsening personal problems to suicide (Bouhoutsos, Holroyd, Lerman, Forer, & Greenberg, 1983). The American Psychological Association’s (2002) "Ethical Principles of Psychologists and Code of Conduct" clearly addresses sexual intimacies between therapists and current and former patients, emphatically forbidding sexual intimacies with current clients. Sexual relations with former clients following termination are also forbidden, except under very limited circumstances. The Ethics Code does not, however, contain general guidelines for therapists who develop sexual attraction to their clients or for those who consider disclosing these feelings to their clients. A brief review of the literature on sexual attraction, management of sexual feelings, and self-disclosure provides the backdrop for a more detailed examination of the topic of therapist self-disclosure of sexual feelings and its relation to the Ethics Code.

Sexual Attraction
Research shows that sexual attraction in therapy is a very common phenomenon; even the popular television show The Sopranos has addressed the issue (Gabbard, 2002). Studies have indicated that most therapists across mental health disciplines, roughly between 70% and 90% of clinicians, have been attracted to at least one client (Bernsen, Tabachnick, & Pope, 1994; Blanchard & Lichtenberg, 1998; Housman & Stake, 1999; Nickell, Hecker, Ray, & Bercik, 1995; Pope, Keith-Spiegel, & Tabachnick, 1986; Pope, Tabachnick, & Keith-Spiegel, 1987; Rodolfa et al., 1994). The majority of therapists have also viewed these feelings as being ethical (Meek & McMinn, 1999; Nickell et al., 1995; Pope et al., 1987). By comparison, the rate of therapists’ sexual involvement with clients ranges from about 2% to 10% (Bouhoutsos et al., 1983; Holroyd&Brodsky, 1977; McMinn&Meek, 1996; Pope et al., 1986; Rodolfa et al., 1994; Stake & Oliver, 1991) and appears to be on the decline (Borys & Pope, 1989).

Managing Sexual Feelings
Therapists’ sexual feelings are often associated with a variety of positive feelings such as enjoyment of working with the client and enhanced empathy (Ladany et al., 1997; Rodolfa et al., 1994) as well as negative feelings such as guilt, anxiety, and shame (Bernsen et al., 1994; Harris, 2001; Ladany et al., 1997; Nickell et al., 1995; Rodolfa et al., 1994) that can sometimes alter the process of therapy. When therapists experience such feelings, many are unlikely to know how best to proceed, as approximately half of mental health professionals have not had any formal training (e.g., through classes, didactics, supervision, or consultation) about ways to effectively manage these reactions (Bernsen et al., 1994; Blanchard & Lichtenberg, 1998; Nickell et al., 1995; Pope et al., 1986; Rodolfa et al., 1994). In spite of the fact that those who have received training have reported a wide range of quality (Bernsen et al., 1994; Blanchard&Lichtenberg, 1998; Ladany et al., 1997; Pope et al., 1986; Pope&Tabachnick, 1993; Rodolfa et al., 1994), perhaps not surprisingly these therapists tend to be the ones who have reported greater confidence in handling issues of sexual feelings when they arose in therapy (Blanchard & Lichtenberg, 1998).

To manage sexual feelings, some clinicians opt to discuss them in supervision, in consultation with colleagues (Bernsen et al., 1994; Blanchard & Lichtenberg, 1998; Housman & Stake, 1999; Pope et al., 1986; Rodolfa et al., 1994), or in their own personal therapy (Pope, 1987). In these settings, therapists can process their emotions in hopes of understanding more about themselves, their clients, and the therapeutic relationship (Bridges, 1994). Two of the most important and helpful things supervisors, consultants, and educators can do in this regard is to normalize feelings of attraction (Bridges, 1998, 1999; Hamilton & Spruill, 1999; Housman & Stake, 1999; Ladany et al., 1997) and distinguish these feelings from sexual misconduct (Gorton, Samuel, & Zebrowski, 1996; Hamilton & Spruill, 1999; Rodolfa, Kitzrow, Vohra, & Wilson, 1990).

Self-Disclosure
A few therapists consider managing their sexual feelings by disclosing them directly to their clients (Pope et al., 1987; Stake&Oliver, 1991). However, the use of self-disclosure in this manner touches on important boundary issues. Research on self-disclosure in general (i.e., unrelated to sexual feelings) indicates that it is a very common therapy technique that almost all therapists view as ethical (Pope et al., 1987). Generally, self-disclosure leads to positive outcomes with clients, especially when the disclosures attempt to normalize and reassure (Hill, Mahalik, & Thompson, 1989; Knox, Hess, Petersen, & Hill, 1997); results are judged less helpful when the disclosure is more confrontational or when it comments on the process of the therapy. A consideration in using self-disclosure is that in cases of therapist sexual misconduct, self-disclosure is often an early boundary crossing heralding a perilous slide toward some type of therapist–client sexual involvement (Gutheil & Gabbard, 1993, 1998; Simon, 1995; Somer & Saadon, 1999; Strasburger, Jorgenson, & Sutherland, 1992). Furthermore, when reflected on, self-disclosure can be an indication that there is something else occurring within the therapeutic relationship. However, in the vast majority of cases, self-disclosure has not led to more serious sexual boundary transgressions (Gabbard, 2001; Simon, 2001).

Therapist Self-Disclosure of Sexual Feelings
Although a few researchers have written on therapist self-disclosure of sexual feelings, the topic remains ripe for further investigation. Overall, reviews focusing on the topic are hard to come by because most use the issue as an addendum to a larger topic (e.g., sexual attraction, sexual misconduct, boundary issues). In addition, there is a general lack of consensus regarding its use and the ethical nature of such disclosures. Furthermore, there is preliminary evidence that training in this area has not had the desired effect of inhibiting disclosures of sexual feelings (Gorton et al., 1996). My intent in the remainder of this article is to provide a review of the topic by incorporating information both from empirical investigations and case studies. In addition, by using the American Psychological Association (2002) Ethics Code as an aid in evaluating different aspects of these disclosures, the objective is to come to more specific conclusions regarding therapists’ use of self-disclosure of sexual feelings.

Prevalence
Despite the fact that using general self-disclosure with clients is common among clinicians, few therapists self-disclose sexual attraction. Across mental health disciplines, roughly between 5% and 25% have ever disclosed sexual attraction to a client, although most figures hover around 5% to 10% (Blanchard & Lichtenberg, 1998; McMinn & Meek, 1996; Nickell et al., 1995; Pope & Tabachnick, 1994; Pope et al., 1987; Stake & Oliver, 1991). In addition, not only is disclosing sexual feelings uncommon, but many therapists have questioned the ethics of doing so (Harris, 2001; McMinn & Meek, 1996; Pope et al., 1987). Of those therapists who did tell their clients that they were sexually attracted to them, they were significantly more likely to be men (Pope et al., 1987; Stake & Oliver, 1991).

Empirical Studies
In one of the few empirical studies to focus on therapist self-disclosure of attraction, Goodyear and Shumate (1996) used an analogue design (via audiotaped mock sessions) to investigate the perceived consequences of therapists’ disclosure of attraction to clients when the disclosure was followed by an indication that no sexual activity would occur. Results showed that although the therapist in the disclosure condition was judged as more attractive than the nondisclosing therapist, the nondisclosing therapist was judged as more expert (although therapists were equal on a measure of trustworthiness). In addition, the disclosure condition was rated as a less therapeutic intervention when compared to the nondisclosure condition. Therapists judged the female therapist as more expert than the male therapist regardless of the condition. Overall, these results may be considered in the context of research that has indicated most therapists question the ethics of self-disclosure of sexual attraction (Blanchard & Lichtenberg, 1998; Harris, 2001; Nickell et al., 1995; Pope et al., 1987). The work of Goodyear and Shumate extends these findings that therapists view self-disclosure of attraction cautiously by questioning the expertise and effectiveness of sexually self-disclosing therapists.

In contrast to the work of Goodyear and Shumate (1996), Giovazolias and Davis (2001) found that therapist self-disclosure of attraction maybe beneficial. More specifically, therapists reported that when they developed sexual attraction for clients, those who disclosed the attraction to clients viewed the effect of the attraction on the therapy as more positive than did therapists who did not disclose their attraction  (Giovazolias & Davis, 2001). The findings are especially interesting given that Giovazolias and Davis surveyed psychologists about their actual experiences. However, the possibility exists that the positive outcomes reported by therapists who disclosed their attraction may have had an element of self-service to them; for instance, They may have been more likely to claim that the results of their attraction and subsequent disclosures were positive rather than negative.

Furthermore, the lack of data from the clients (individuals who were in a better position to judge the effect of therapists’ attraction and disclosures) as well as the small number of psychologists who disclosed their feelings limits the conclusions that can be drawn from these findings. In a study of how male and female therapists respond to sexual material that clients bring up in therapy, Schover (1981) used audiotapes of mock therapy sessions to assess therapists’ responses to sexual seduction and discussions of sexual dysfunction. With seductive female clients, male therapists made many self-disclosing comments including self-disclosing sexual attraction to the client. Female therapists were not similarly self-disclosing in the seductive male client condition.

Therefore, clinicians need to be vigilant about how they respond to clients who are perceived as presenting themselves in a sexual manner. Prudence indicates that it may be increasingly important for male clinicians to monitor themselves in these situations and question their motives in considering whether to disclose sexual attraction to a client (Goodyear & Shumate, 1996; Schover, 1981).
- Fisher, Craig D., Ethical issues in therapy: therapist self-disclosure of sexual feelings; Ethics & Behavior, Apr 2004, Vol. 14, Issue 2.

Personal Reflection Exercise #5
The preceding section contained information on therapist self-disclosure of sexual feelings. Write three case study examples regarding how you might use the content of this section of the Manual in your practice.

QUESTION 15
To manage sexual feelings, some clinicians opt to discuss them in supervision, in consultation with colleagues, or in their own personal therapy. What are two of the most important and helpful things, consultants, and educators can do in this regard?