Ethics Implementing Multicultural Ethics: Issues for Family Counselors C. Bret Hendricks1, Loretta J. Bradley1, and Derek L. Robertson2 Abstract This article addresses the need for family counselors to examine the application of new constructs to counseling ethics training. The authors believe that current ethics training is deficient in integrating high-level cognitive decision models and multicultural constructs. The authors challenge family counselors to expand their cultural perspectives in ethical decision making and cease ethics training that is inadequate to meet the needs of a diverse society. Keywords ethics training, cognitive decision models, multicultural constructs, family counselors Case Study ‘‘Uh oh,’’ Elaine Miller exclaimed. Elaine, a family counselor in a large southern city, is having lunch with her friend, Paula, also a family counselor. ‘‘Paula, I honestly thought that I had done the ethics training for this license renewal, then I remem- bered I wasn’t feeling well when we had the training with the local group,’’ Elaine explains. ‘‘Well,’’ Paula says with a dis- missive hand wave, ‘‘They went through the new state require- ments. Otherwise, you didn’t miss much. Just the same old stuff.’’ Paula described the training, explaining that the trainers provided updates regarding new state requirements for docu- mentation and informed consent. She concluded by reassuring Elaine, ‘‘You can get that stuff from the website.’’ Elaine sighed and glanced over her shoulder. Then, looking at Paula in a conspiratorial manner, she said, ‘‘You know, I think I might have ‘gotten sick’ on purpose just to not have to go to the same boring training again. I just hate having to go and listen to stuff that I can look up myself. These trainings are just excru- ciating.’’ Sighing again, she went on to say, ‘‘The only good thing about ethics training is being able to see my friends, because I never really hear anything that helps me.’’ She relaxes a bit, nods to herself and tells Paula, ‘‘I’ll just find something on-line and get it done tonight. That’s easier any- way.’’ ‘‘Now, I have a real ethics question for you, Paula.’’ I have this case that I just don’t get. I am so stressed about this case. Maybe you can help me. You see, I’m seeing a family from Paki- stan and they have all their relatives living with them. The hus- band’s parents don’t ever leave the house; they just sit there and tell everyone what to do. The whole family just revolves around any little thing that the grandparents want. Also, the parents don’t allow their kids to do anything because the grandparents want the kids home from school immediately. I know that I need to work with the whole family, I just don’t know how to do it and really help them. Every family counselor is confronted with questions that challenge his or her ethical beliefs; questions that are not answered in simple dichotomous terms of right/wrong. More- over, famil ...

1. Ethics
Implementing Multicultural Ethics:
Issues for Family Counselors
C. Bret Hendricks1, Loretta J. Bradley1, and Derek L.
Robertson2
Abstract
This article addresses the need for family counselors to examine
the application of new constructs to counseling ethics training.
The authors believe that current ethics training is deficient in
integrating high-level cognitive decision models and
multicultural
constructs. The authors challenge family counselors to expand
their cultural perspectives in ethical decision making and cease
ethics training that is inadequate to meet the needs of a diverse
society.
Keywords
ethics training, cognitive decision models, multicultural
constructs, family counselors
Case Study
‘‘Uh oh,’’ Elaine Miller exclaimed. Elaine, a family counselor
in a large southern city, is having lunch with her friend, Paula,
also a family counselor. ‘‘Paula, I honestly thought that I had
done the ethics training for this license renewal, then I remem-

2. bered I wasn’t feeling well when we had the training with the
local group,’’ Elaine explains. ‘‘Well,’’ Paula says with a dis-
missive hand wave, ‘‘They went through the new state require-
ments. Otherwise, you didn’t miss much. Just the same old
stuff.’’ Paula described the training, explaining that the trainers
provided updates regarding new state requirements for docu-
mentation and informed consent. She concluded by reassuring
Elaine, ‘‘You can get that stuff from the website.’’ Elaine
sighed and glanced over her shoulder. Then, looking at Paula
in a conspiratorial manner, she said, ‘‘You know, I think I
might have ‘gotten sick’ on purpose just to not have to go to the
same boring training again. I just hate having to go and listen to
stuff that I can look up myself. These trainings are just excru-
ciating.’’ Sighing again, she went on to say, ‘‘The only good
thing about ethics training is being able to see my friends,
because I never really hear anything that helps me.’’ She
relaxes a bit, nods to herself and tells Paula, ‘‘I’ll just find
something on-line and get it done tonight. That’s easier any-

3. way.’’ ‘‘Now, I have a real ethics question for you, Paula.’’
I have this case that I just don’t get. I am so stressed about this
case.
Maybe you can help me. You see, I’m seeing a family from
Paki-
stan and they have all their relatives living with them. The hus-
band’s parents don’t ever leave the house; they just sit there and
tell everyone what to do. The whole family just revolves around
any little thing that the grandparents want. Also, the parents
don’t
allow their kids to do anything because the grandparents want
the
kids home from school immediately. I know that I need to work
with the whole family, I just don’t know how to do it and really
help them.
Every family counselor is confronted with questions that
challenge his or her ethical beliefs; questions that are not
answered in simple dichotomous terms of right/wrong. More-
over, family counselors find themselves working with clients
who are increasingly diverse; that is, vastly different from their

4. own families and cultures of origin. Many family counselors
grew up having never known persons of widely divergent ethi-
cal cultural beliefs. The purpose of this article is to provide a
more thorough perspective of diverse cultural ethical beliefs
to which most family counselors have little or no exposure.
Ethical Dilemma
While professional family counselors agree that ethical compe-
tence is mandatory, they are ill- prepared to practice systemic
ethics that encompass higher level moral and cultural con-
structs. Hill (2004) reported the most commonly taught topics
presented in counselor education ethics courses are: confiden-
tiality, duty to warn, informed consent, dual relationships,
scope or practice, sexual harassment, and record keeping. Fur-
ther, although it is given that counseling programs must offer at
1 Department of Educational Psychology and Leadership, Texas
Tech
University, Lubbock, TX, USA
2
Department of Counseling, University of Texas San Antonio,
San Antonio,

5. TX, USA
Corresponding Author:
C. Bret Hendricks, Department of Educational Psychology and
Leadership,
Texas Tech University, 3008-18th, Lubbock, TX 79409, USA.
Email: [email protected]
The Family Journal: Counseling and
Therapy for Couples and Families
2015, Vol. 23(2) 190-193
ª The Author(s) 2015
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least one course in ethics, these courses are usually taught in a
lecture format. However, despite this format, traditionally prac-
ticed for years, there is compelling evidence suggesting that
this teaching modality may not be the best format (Cook-
Greuter & Soulen, 2007). Further, Warren, Zavaschi, Covello

6. and Zakaria (2012) write that ethics is a broad topic requiring
more than a simple lecture format. Corey, Corey and Callanan
(2011) posit that counselor educators must consider that stu-
dents’ progress from conceptual issues to active learning and
practical application. Other researchers found that effective
ethics training challenges students to transform their current
ways of thinking to more integrated processes, including case
study (Cook, Greuter, & Soulen, 2007). Credence for these
findings is provided by McAuliffe and Eriksen (2011) who
conclude that ethics training should emphasize the use of crit-
ical analyses through case studies. McAuliffe and Eriksen
(2011) further write that ethics training should emphasize
high-level moral and ethical reasoning rather than simplistic
solutions that are inherently unrealistic.
Ethics Training and Multicultural
Perspectives
Ethics training should provide students training in multicul-
tural perspectives. Cannon (2005) writes that students must
consider multicultural perspectives in ethics training. Accre-

7. dited counselor education programs provide at least one course
in multicultural counseling (CACREP, 2009). However, these
multicultural courses are only an introduction to what should
be an ongoing conversation (Cannon, 2005; Watt, Robinson &
Smith, 2002). First and foremost, they are charged with prepar-
ing students with the skills, knowledge, and awareness to work
with those minorities that they are most likely to encounter in
their work. These are groups who, at some level, are forced to
adjust their lives when dealing with the dominant culture. While
these classes typically do employ some interpersonal and
experi-
ential activities, they normally lack the depth and continuity to
promote more comprehensive schemas around culture and val-
ues (Cannon, 2005; Endicott, Bock & Narvaez, 2003). These
courses may provide students with insight however; the reduc-
tion of bias often rests at an intellectual level. Affective bias,
implicit bias, or aversive racism often remain unchanged
(Auger,
2004; Boysen, 2010; Boysen & Vogel, 2008).

8. Humans have a natural tendency toward ethnocentricity and
mental health practitioners are no less ethnocentric than the
typical nonprofessional (Leong & Santiago Rivera, 1999). Ideas
about what is right and wrong are often so ingrained that they
escape examination. A lifetime of conditioning by one’s culture
as to what is correct, proper, or moral makes it difficult for one
to differentiate between what is merely a social construction
and
what is a ‘‘truth’’ that transcends culture. Americans often fail
to
recognize the value of learning from other cultures. They see
the
United States as a world leader and assume that where others
do things differently they have simply not yet been enlightened
as to the benefit of being like the United States (Anderson,
Lawton, Rexeisen, & Hubbard, 2006).
These sentiments are echoed by Leong and Santiago-
Rivera (1999) who note that one of the challenges for global
multiculturalism is the ‘‘false consensus effect’’ where one

9. assumes that his or her behavior, values, or reactions are the
norm and that others would naturally agree or behave simi-
larly. Therefore, counselors may assume that theories and
techniques or values that resonate with them will be effective
or make sense to all clients, regardless of differences in cul-
ture or contexts.
Thus, much can be learned about human nature from exam-
ining cultures with different values frameworks—not just those
that are considered minorities within our borders but also those
that are outside of the United States. Even if one never sees an
individual client or family from India or Zimbabwe, learning
about those cultures can provide a mirror to reflect assumptions
about human nature and what is considered ‘‘right’’ or
‘‘wrong.’’
Examples of child rearing practices, education, faith, rituals,
and
ethics from around the globe can provide a contrast that helps
students to see their own culture and be more vigilant and aware
in regard to their assumptions.

10. A single course in multiculturalism is insufficient to pro-
duce the necessary openness and awareness needed to under-
stand the limitations of one’s culture on others (Cannon, 2005;
Watt, Robinson, & Lupton Smith, 2002) and to acknowledge
unintentional bias (Auger, 2004; Boysen, 2010; Boysen &
Vogel, 2008). Infusion of multiculturalism into the full coun-
selor education curriculum is necessary to counteract the life-
long conditioning students have had. Because undetected
biases related to values are often deeply embedded, it is cru-
cial that counselor educators challenge students with multi-
cultural perspectives in their ethics training while
supporting them to make sense of and find appreciation for the
way others address moral issues.
Thus, a salient question arises. Do family counselors
have appropriate training and understanding of multicultural
perspectives in ethics? The authors posit this understanding
is lacking and is based upon deficits in current training
modalities which at best, are outdated; while they may be

11. at worst, deficient in meeting the complex needs of a chang-
ing world. In this article, we present a plan whereby family
counselors may begin to deepen their understanding of cul-
tural ethics.
As the previous paragraphs indicated, the authors believe
that present ethics training in counseling programs generally
family counseling programs specifically do not meet the
needs of a complex and diverse society. Thus, the authors are
issuing a 2-fold challenge. First, counselor educators in fam-
ily counseling programs need to teach ethics using higher
level critical analyses, including higher levels of moral rea-
soning and cultural ethics. Second, continuing education
related to counseling ethics must address these same areas,
thereby providing appropriate counseling training for practi-
cing family counselors. Further, the authors assert that profes-
sional family counselors must challenge current training
paradigms that seem woefully inadequate in meeting their
needs.

12. Hendricks et al. 191
Case Study
Rose immigrated to the United States from a Sub-Saharan
African
country. She came to the United States as a refugee and was
work-
ing with a counselor on issues related to trauma, adjusting to
the
culture, and everyday life of living in the United States. Rose
dis-
closed that in her home country her husband had a second wife.
The
counselor expressed sympathy and concern for Rose. Although
Rose immediately let her counselor know that her husband
taking
a second wife was not the problem, ‘‘She is like my sister. How
can
I take care of the house, the children, and our husband without
her?’’ While counselors may have legitimate concerns about
women around the world who are not empowered, these were
not

13. Rose’s immediate concerns. Rose’s values were centered on
taking
care of her family in an environment that is vastly different
from
the one most counselors in the West can relate to.
Critical examination of the hegemony of Western ethics and
communication styles is necessary as each family counselor
considers his or her ethical framework and communication
style.
It is problematic that those in western cultures have not chal-
lenged the primacy of western ethics. Essentially, many family
counselors may be unwittingly problematizing client issues due
to ignorance of other worldviews. For example, Western cul-
tures prize autonomy, identified by Kitchener (1984) as a basic
tenet of ethics. However, clients from eastern cultures value
communitarian beliefs and filial alliance and adherence to moral
virtues. In considering another culture, followers of Confucius
believe in the concept of Ren that compels believers to adhere
to the moral codes of their ancestors. Thus, autonomous
decision making is not encouraged in favor of consideration of

14. ancestral values as guiding principles of morality and ethics.
Conclusion
In conclusion, the authors challenge all family counselors to
broaden their cultural perspectives in ethical decision-making
and communication styles. The authors further challenge fam-
ily counselors to cease maintenance and facilitation of ethics
training which is inadequate to meet the needs of a diverse soci-
ety. Ethics training should, at its core, value multicultural per-
spectives. Most ethics training in counselor education
programs and continuing education programs is based upon
lecture format that promotes passivity and does not adequately
challenge participants to integrate complex ethical decision-
making constructs. Furthermore, counselor training, often,
does not train family counselors in optimum communication
styles that meet the needs of their clients. We have, in the coun-
seling profession, adopted a stance that is, without intent, per-
petuating Western notions of ‘‘right’’ and ‘‘wrong,’’ while not
accounting for other philosophical points of view.

15. The issues addressed by the authors in this article cannot be
remedied easily. Simplistic solutions are not adequate to meet
the complexities of cultural integration into family counseling.
This article and its concurrent findings have compelled the
authors to conduct further research to explore the issues with
the intent to provide specific strategies from other cultures
which may be incorporated into family counseling practice.
The authors believe that this article provides a beginning stage
for exploring existing milieus of counseling ethics training and
critically examining whether or not present modalities of train-
ing are effectively meeting the needs of family counselors.
Additionally, the authors will pursue further research into the
similarities and differences in autonomous communitarian
approaches to moral philosophies, especially as they relate to
family counseling. Through addressing pluralistic approaches,
family counselors will benefit by using philosophies and tradi-
tions of ethical decision making and communication when
searching for ethical practices that meet the needs of the ever-

16. shifting perspectives of a multicultural society.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research,
author-
ship, and/or publication of this article.
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A Call for More Talk and Less Abuse in the Consulting Room:
One Psychoanalyst–Sex Therapist’s Perspective
Elizabeth R. Goren, PhD
New York University
Guilt, titillation, and anxious confusion about sexuality and
sexual relations between therapist and patient
pervade the psychoanalytic community. Review of state laws
and regulations as well as professional
ethics codes reveals a lack of certainty about what constitutes
professional misconduct, especially
posttermination. Comparing the training approaches of sex
therapy and psychoanalysis, the author
suggests that psychoanalysis will benefit from shifting its focus
on extreme cases of egregious sexual
boundary violations onto greater in-depth exploration of
clinically universal experience of powerful
erotic and negative transference and countertransference.
Innovative and experiential educational formats
that promote openness, acceptance, confidence, and skill with
these dynamics are the best prevention.
Keywords: psychoanalysis, sex therapy, boundary violations,
ethics training
I was a sex therapist for many years before becoming an
analyst.

29. My training in sex therapy took place in the 1970s, the era of
sexual liberation and the initial rise of the behavior therapy
move-
ment, before the terms sexual boundary violations (SBV) and
risk
management had entered professional discourse. One of my first
sex therapy courses involved a series of role-playing exercises,
including one of taking turns giving and receiving massage, a
standard sex therapy homework assignment. This is a teaching
tool
that could never be a part of a professional curriculum in
today’s
climate of increased sensitivity to sexual abuse and risk
manage-
ment approach to training and education. We were clothed, and
touch was restricted to the kind of back, neck, arms, and hands
massage now offered in airports and nail salons. Role-playing
patient and therapist, we talked about our bodies and sexuality
in
a very personal and detailed way with one another.
I offer this vignette in the spirit of bringing the perspective of
other treatment models, specifically sex therapy, to our
psychoan-
alytic approach to the problem of SBV. As I look back, I recall
my
sex therapy mentors repeatedly and sharply reminding us how
crucial it was to maintain the therapeutic frame and professional
boundaries. The reputation and very legitimacy of this new form
of
psychotherapy were at stake. To this day, sex therapists are
mind-
ful of not being confused with sex surrogates!
Despite the marked differences in thinking and approach, psy-
choanalysis and sex therapy are the treatment modalities most

30. dedicated to intense clinical work with sex and sexuality. How-
ever, in contrast to psychoanalysis, sex therapy has historically
taken a strong unambiguous stand against therapists ever
becom-
ing sexually or romantically involved with patients. Equally im-
portant, sex therapy is more dedicated than psychoanalysis to
training that focuses on developing “sex-positive”
communication,
that is, talking about sex in a thoughtful, self-aware, and
sensitive
way that conveys professionalism, respect for the patient, and
absolute clarity about the frame and boundaries that I believe
reduces the therapist’s as well as patient’s anxiety and resultant
vulnerability to acting out.
Psychoanalysis has begun to focus on the problem of SBV, with
identification of personal risk factors and theoretical issues. I
will
focus on aspects of clinical practice, specifically the technical
reliance on the patient–therapist relationship, and the culture of
psychoanalysis itself—namely, attitudes toward sexuality and
sex-
ual abuse—that are relevant to SBV and the need for greater
consideration in analytic training and education.
Psychoanalysis and Sexual Abuse: A Society and
Profession in Turmoil
Although we live in an era of unprecedented sexual liberalism
and public intolerance of sexual abuse, actual behavioral
reactions
to abuse can be wildly inconsistent and hypocritical. Public
proc-
lamations of moral condemnation stand side by side with “Look
the other way” attitudes. We hear of discretionary measures or

31. organized cover-ups of SBV, depending on your outlook, that
take
place in religious institutions, universities, and professional
orga-
nizations, including psychoanalysis. At the same time, we hear
of
policies of zero tolerance taken to punitive extremes, such as a
report of an Arizona school punishing a 5-year-old
kindergartner
for pulling his pants down in the playground with detention and
having his permanent record marked with sexual misconduct
(Crimestaffer Staff, 2014).
Psychoanalysis reflects these mixed messages and moral con-
fusion. Beyond a consensus that physically actualized sexual ac-
tivity between analyst and patient in the course of treatment is
inappropriate, there is little agreement about what kinds of
actions
and relations between patient and analyst constitute abuse or
exploitation and what should be done about it. For instance,
once
the person is no longer in treatment, in the view of some
analysts
as well as laymen, because the person is not in a formal patient–
analyst relationship, the relationship falls outside the category
of
Correspondence concerning this article should be addressed to
Elizabeth
R. Goren, PhD, Postdoctoral Program in Psychotherapy and
Psychoanal-
ysis, New York University, 300 Mercer Street, Suite 23L, New
York, NY
10003. E-mail: [email protected]
T
hi

32. s
do
cu
m
en
t
is
co
py
ri
gh
te
d
by
th
e
A
m
er
ic
an
P
sy
ch

33. ol
og
ic
al
A
ss
oc
ia
ti
on
or
on
e
of
it
s
al
li
ed
pu
bl
is
he
rs

34. .
T
hi
s
ar
ti
cl
e
is
in
te
nd
ed
so
le
ly
fo
r
th
e
pe
rs
on
al

35. us
e
of
th
e
in
di
vi
du
al
us
er
an
d
is
no
t
to
be
di
ss
em
in
at

36. ed
br
oa
dl
y.
Psychoanalytic Psychology © 2017 American Psychological
Association
2017, Vol. 34, No. 2, 215–220 0736-9735/17/$12.00
http://dx.doi.org/10.1037/pap0000092
215
mailto:[email protected]
http://dx.doi.org/10.1037/pap0000092
potential SBV. Others strongly disagree. On hearing of a
colleague
becoming involved with a person he or she is currently seeing
or
has seen in the past for treatment, the markedly mixed reactions
I
have heard include the following:
“If they live happily ever after, what harm is there? It happens
all the time.” (Read, what’s the big deal?)
“I do not believe it,” followed by either “The patient must be
borderline” (read, the one who must be responsible) or “He
needs help” (read, it must be mental illness).
“She transgressed?” (Read, a woman? How could that be?)

37. “He’s a psychopathic predator.” (Read, a man, figures. He’s
a criminal. Punish the bastard.)
“How could I have not seen the signs?” (Read, I must be
responsible in some way.)
And finally, “How could this be true of my mentor, our
institute’s leader?” (Read, what does this mean about psycho-
analysis itself, the field I have put my career, my life, my faith
in as a philosophy of life?)
The story of psychoanalysis is littered with stories of some of
its
most renowned leaders becoming sexually involved with their
patients. Reactions to tales of Carl Jung with Sabina Spielrein,
Erich Fromm with Frieda Fromm Reichman, Sandor Ferenczi
with
Gisella Palos, and Margaret Mahler with August Aichorn range
from fascination to abhorrence but de facto acceptance. And
with-
out “naming names,” the reader will surely know living leaders
whose sexual relations with patients have made for sensational
gossip while retaining the analytic tradition of reverence for the
personal and intellectual authority of the leader. Our “standard
operating practice” of “Do not condone but look the other way”
cannot be denied.
The very term SBV conveys our erotic horror (Grand, in press),
guilt-laced titillation, and a nearly paralyzing anxiety about the
issue that manifests in confusion and inability to locate a moral
position that is neither permissive nor excessively punitive, that
is,
a stand that can be consistently upheld in practice. We speak
neutrally of boundaries, but we end up talking moralistically of
violators and transgression (implying criminality) or

38. empathically
of rehabilitation (implying illness). We proclaim a moral
absolut-
ism for the basic precept—the therapist–patient relationship is
sacred and sexual romantic involvement wrong and harmful—
while living a moral relativism that is as much borne of our
internalized cultural ambivalence toward sexual abuse and
exploi-
tation, as it is our analytic recognition of the complexity behind
human behavior.
When the possibility of a SBV by an analyst comes to the fore
in an analytic community, we react like any other family or
community. First, we circle the wagons. The initial shock, hand
wringing, and gossip may provoke a call for more talks and
workshops on the subject, in the spirit of doing the analytic
thing—trying to understand. If the analyst has less visibility and
stature, he or the occasional she is quietly shuttled out of the
analytic fold, scapegoated, and shunned in fear of contagion and
guilt by association, the one that is turned into the negative
model—the exception that proves the rule. If the analyst is a
senior, highly respected analyst, particularly if the person has
made extraordinary contributions to the field, the community is
more likely to be traumatized and in need of collective healing
(Honig & Barron, 2013). Periodic flooding pierces institutional
patterns of avoidance. A sudden bystander helplessness, a
simul-
taneous wanting but not wanting to look away, a wanting and
not
wanting to know what is known, ends in a press on program
directors and ethics committees to “do something,” mirroring
family and organizational dynamics of abuse. They, in turn,
look
to their professional ethics codes and seek legal counsel and the
guidance of their state regulatory board.

39. The ironic twist is that existing laws and regulations of profes-
sional misconduct, having been greatly based on professional
definitions of abuse and exploitation, manifest inconsistencies
in
ethical standards that are similar to what we see in
psychoanalysis.
The various professional codes of conduct concur on prohibiting
sexual relations with persons currently in therapy. Where they
vary
is on the matter of posttermination sexual relations and in ways
that suggest differences in thinking among the disciplines.
The American Psychoanalytic Association (2009 –2016) leaves
no room for equivocation: “Sexual relationships involving any
kind of sexual activity between the psychoanalyst and a current
or
former [emphasis added] patient, by the treating psychoanalyst,
are
unethical.” It goes so far as to declare that
marriage between a psychoanalyst and a current or former
patient, or
between a psychoanalyst and the parent or guardian of a patient
or
former patient is unethical, notwithstanding the absence of a
com-
plaint from the spouse and the legal rights of the parties.
Similarly, the American Association of Sex Educators Counsel-
ors and Therapists (2016), a longstanding organization for prac-
ticing sex therapists, takes a clear-cut strict position of
prohibiting
posttermination romantic/sexual involvement with former
clients/
patients and their close family members. The code of conduct

40. also
includes certain nonphysicalized verbal interactions in defining
abuse and maintains a position that the patient–therapist
relation-
ship remains unequivocally professional “in perpetuity”:
The member practicing counseling or therapy shall not engage,
at-
tempt to engage or offer to engage a consumer in sexual
behavior
whether the consumer consents to such behavior or not. . . .
Sexual
mis-conduct includes kissing, sexual intercourse and/or the
touching
by either the member or the consumer of the other’s breasts or
genitals. Members do not engage in such sexual misconduct
with
current consumers. . . . Sexual misconduct is also sexual
solicitation,
physical advances, or verbal or nonverbal conduct that is sexual
in
nature. . . . For purposes of determining the existence of sexual
misconduct, the counseling or therapeutic relationship is
deemed to
continue in perpetuity [emphasis added].
The National Association of Social Workers (NASW, 2016), the
professional organization for licensed social workers whose
prac-
tice includes but is not limited to psychotherapy and which
applies
to certain members of Division 39, holds to the following
princi-
ple: “Social workers should not engage in sexual activities or
sexual contact with former clients because of the potential for
harm to the client.” Furthermore, it goes on to declare,

41. T
hi
s
do
cu
m
en
t
is
co
py
ri
gh
te
d
by
th
e
A
m
er
ic
an
P

42. sy
ch
ol
og
ic
al
A
ss
oc
ia
ti
on
or
on
e
of
it
s
al
li
ed
pu
bl
is

43. he
rs
.
T
hi
s
ar
ti
cl
e
is
in
te
nd
ed
so
le
ly
fo
r
th
e
pe
rs

44. on
al
us
e
of
th
e
in
di
vi
du
al
us
er
an
d
is
no
t
to
be
di
ss
em

45. in
at
ed
br
oa
dl
y.
216 GOREN
If social workers engage in conduct contrary to this prohibition
or
claim that an exception to this prohibition is warranted because
of
extraordinary circumstances, it is social workers—not their
clients—
who assume the full burden of demonstrating that the former
client
has not been exploited, coerced, or manipulated, intentionally or
unintentionally [emphasis added].
Finally, we have the American Psychological Association
(APA, 2010) ethics code, the code of conduct currently in place
for
psychologist members of Division 39. Like the NASW code, the
APA code includes but is not limited to professionals practicing
psychotherapy and reflects multiple theoretical perspectives.
This
code specifies a 2-year posttermination clause that recognizes
the

46. power of transference but leaves much room for personal judg-
ment. Principle [b] of 10.08 states,
Psychologists do not engage in sexual intimacies with former
clients/
patients even after a two-year interval except in the most
unusual
circumstances [emphasis added]. Psychologists who engage in
such
activity after the two years following cessation or termination
of
therapy and of having no sexual contact with the former
client/patient
bear the burden of demonstrating that there has been no
exploitation,
in light of all relevant factors [emphasis added], including (a)
the
amount of time that has passed since therapy terminated; (b) the
nature, duration, and intensity of the therapy; (c) the
circumstances of
termination; (d) the client’s/patient’s personal history; (e) the
client’s/
patient’s current mental status; (f) the likelihood of adverse
impact on
the client/patient; and (g) any statements or actions made by the
therapist during the course of therapy suggesting or inviting the
possibility of a post termination sexual or romantic relationship
with
the client/patient. (See also Standard 3.05, Multiple
Relationships.)
In terms of legal and regulatory standards, every state prohibits
professional sexual misconduct through its state licensing
boards
(Pope, 2001). And at least, or only, again depending on your
outlook, 23 states have enacted legislation making sexual

47. contact
between therapists and patients in the course of therapy a
criminal
offense (Berkowitz Glasgow, 1992). Landmark legislation in
1984
by Wisconsin remains one of the wider ranging:
Any person who is or holds himself or herself out to be a
therapist and
who intentionally has sexual contact with a patient or client
during
any ongoing therapist-patient or therapist-client relationship,
regard-
less of whether it occurs during any treatment, consultation,
interview
or examination, is guilty of a Class D felony. (Wis. Stat. Ann. &
940.22(2) (West Supp. 1990), as cited in Berkowitz Glasgow,
1992)
Legal determination of the extent of harm varies by what,
where, and when the sexual contact took place, such as whether
it
occurred inside or outside the consulting room, and usually only
applies to conduct occurring while in treatment. In New York,
for
instance, a therapist, counselor, psychologist, or psychiatrist
who
has sex with a patient during the course of a treatment session is
guilty of statutory rape. By implication, then, sexual relations
outside the consulting room are considered less harmful, subject
to
a lesser penalty, and potentially not harmful once the person
“terminates” treatment, reflecting the mixed messages of the
pro-
fessions themselves on this issue. The most common legal path
followed in this country for professional sexual abuse is civil

48. litigation, which applies tort law and, as such, serves as the
primary legal avenue for patients seeking potential redress and
for
therapists protection against false accusation.
Professional misconduct is based first on an assumption of harm
and, second, by virtue of the inherent power imbalance, depen-
dency, and intimacy of the patient–therapist relationship, on the
inability of the patient to give full consent. Arguments against
legal or regulatory control of patient–therapist relations are
based
on the principle that the government should not be allowed to
regulate the private activity of consenting adults and on the
prin-
ciple that adults are not minors and therefore capable of
consent.
Psychoanalytic literature has yet to directly, fully address the
questions of harm and consent. Dimen (2011) was the ground-
breaking analyst to have had the courage to write about her
direct
personal experience with SBV. She talked about an incident of
physical violation, the “kiss,” and the effect on her and her
treat-
ment. In the end, she believed that she had been both helped yet
harmed by the analyst and briefly touched on the question of
consent. Although not a direct victim of a SBV, Burka (2008)
wrote about the harm done to her by her analyst in the course of
his
SBV with another patient. She described the trauma she experi-
enced on learning that her analyst had shared information about
her and her treatment with this other patient. Other relevant
liter-
ature on the questions of harm and consent has focused on the
analyst’s use of clinical material (e.g., Aron, 2000; Gabbard,
2000;

49. Kantrowitz, 2004).
Given that we can never be fully aware of our unconscious,
under what conditions can and should we consider a patient
capable of giving informed consent, particularly with regard to
issues in relation to the analyst? Furthermore, if a patient is
never
totally “free” of transference, at what point can we consider a
patient as in or sufficiently out of treatment, and free enough of
transference and unconscious motivation to be capable of
exercis-
ing fully informed consent? Reader, I ask, what say you?
Respon-
sibility for answering these thorny questions gets passed like a
hot
potato between the professions and their governing bodies,
leaving
individual analysts unsure what to think and organizations
unsure
of how to best handle situations involving SBV.
Broad moral questions emerge when violators hold a position of
power and prestige. Should they be allowed to teach, invited to
present? Should we still assign their articles, cite them in our
work? The argument goes something like this. Does a moral
failure
invalidate what an analyst has to offer intellectually? Should a
person who has committed a sexual boundary violation, perhaps,
as is most often true, a single case of transgression with one
patient, be punished and the community robbed of his or her
intellectual contributions?
We witnessed these questions of distinguishing judgment of
behavior from the person when Woody Allen, who was alleged
to
have sexually abused one of his ex-wife’s children and having

50. married another, was given a lifetime achievement award at the
2014 Golden Globes. As Allen (2014) himself put it, “Do you
henceforth cease your admiration of me and my work due to the
admittedly pretty damn compelling evidence that I molested at
least one young child?” Society and psychoanalysis have yet to
find a clear-cut answer to this question.
How Analytic Culture and Practice May Contribute
to SBV Risk
How has the culture and practice of psychoanalysis made it
more a part of the problem than of the solution? First, we have
as
T
hi
s
do
cu
m
en
t
is
co
py
ri
gh
te
d

51. by
th
e
A
m
er
ic
an
P
sy
ch
ol
og
ic
al
A
ss
oc
ia
ti
on
or
on
e

52. of
it
s
al
li
ed
pu
bl
is
he
rs
.
T
hi
s
ar
ti
cl
e
is
in
te
nd
ed

53. so
le
ly
fo
r
th
e
pe
rs
on
al
us
e
of
th
e
in
di
vi
du
al
us
er
an

54. d
is
no
t
to
be
di
ss
em
in
at
ed
br
oa
dl
y.
217SBV IN PSYCHOANALYSIS: A SEX THERAPIST
SPEAKS
yet to form a consensus or offer clear guidance regarding the
question of harm and ethics of posttermination personal
involve-
ment—most critically of involvement that is romantic and/or
sex-
ual. This leaves open the situation of patients ending treatment

55. with the intent, consciously or unconsciously, to pursue a
romantic
relationship. We saw in their ethics codes that certain profes-
sions—namely, the American Psychoanalytic Association and
the
American Association of Sex Educators Counselors and Thera-
pists—take a stronger stand than the APA code does, that once a
patient always a patient. Although this leaves room for
discretion
in judgment, and taking circumstances in consideration, it begs
the
question for those who look to the profession to take a more
definitive stand that can be upheld as a basic ethical principle.
Certainly more open discussion and guidance of the ethics of
posttermination relations in general are needed and, most
crucially,
of romantic/sexual relations between analyst and former patient.
Second, the groundbreaking work on SBV begun by Gabbard
and his colleagues was first brought to the field’s attention as
late
as the mid-1990s and turn of the century (Gabbard, 1995;
Gabbard
& Peltz, 2001). With the exception of the continued dedication
of
the voices of Gabbard (in press), his colleague Celenza (2007,
2010, in press), and Dimen (2011, in press), few psychoanalytic
leaders have been willing to confront the severity of the
problem,
much less taken a strong stand on the matter. This has a left a
mixed message that, although becoming sexually involved with
patients may be morally wrong and clinically harmful, it is to be
expected as an unfortunate one-off inevitability arising from the
unique intimacy of the analytic relationship, maybe even a part
of
a leader’s mystique. In their study of one institute following a

56. SBV, Honig and Barron (2013, p. 25) reported, “One senior
analyst wondered about our complicity and whether our
idealiza-
tion of X and our narcissistic investment in his significant
contri-
butions to psychoanalysis had blinded us to possible danger sig-
nals.”
In contrast to the relative silence in psychoanalysis, Masters
and
Johnson (1966, 1970, 1977) through their research and clinical
work, became highly vocal advocates of criminalizing therapist–
patient sex, considering it rape. According to Pope (2001), these
founders of sex therapy were responsible for bringing public
attention to professional sexual misconduct. And although
sensa-
tional movies such as Kinsey and Masters of Sex have portrayed
the sexual shenanigans of these leading sexologists, there is a
crucial distinction between ethical responsibility in relation to
colleagues and responsibility to and for patients.
Furthermore, institutes that foster a cult of personality and
general analytic proclivity for leader worship become ripe
climates
for potential exploitation and abuse. Again, compared to the
ana-
lytic tradition of reference to Freud and subsequent
“forefathers,”
sex therapists tend to be far less devotionally bound to their
originators and other leaders. Overarching endowment of faith,
power, and prestige in the field’s leaders not only potentiates
their
vulnerability to overinflated self-esteem but can also contribute
to
personal isolation, a psychological mix that increases an
analyst’s

57. risk.
Psychoanalysis has tendencies to idealize not only its leaders
but
psychoanalysis itself as a therapy practice. It can lead us to be
unrealistic about whom we can help and what we accomplish in
certain treatment situations. This can lead to
countertransferential
resistance and feelings of inadequacy about terminating an
analy-
sis that has reached the limits of what is possible for that
analytic
pair at that time. Today analysts work with pathology that is
sometimes accompanied by acting out, adding to the analyst’s
challenge to maintain boundaries while continuing the
treatment.
The shift in thinking from the ideal analyst image as the all-
knowing father to the all-loving mother also makes it harder for
today’s analysts to accept the limits of a treatment without
feeling
that they have somehow failed. In well-meaning but potentially
doomed efforts to keep trying to rescue a faltering treatment,
analysts risk falling on that slippery slope because they feel the
need for consultation to be a personal weakness. Far more
accept-
ing of our patients’ limitations than of our own, we struggle to
not
take the outcome of the work personally. As Chessick (2001)
pointed out, professional narcissism is “the great enemy of
integ-
rity” and can end up being the downfall of the most gifted and
well-intentioned analyst.
In contrast, the professional identity of sex therapists is that of
helper, not healer, and consequently sex therapists do not hold

58. themselves or their patients to the dream of a “total makeover”
of
the psyche and living. Perhaps we analysts can have a more
open
attitude to treatments that may be limited in frequency, length,
and
goals. Not only will this reduce the paradigm stress on boundary
faltering, but I also think it will enhance our appeal and
relevance
in contemporary society.
Clinical Training on Sex in the Consulting Room
How surprised was I when, as a young sex therapist, I began
analytic training and found my teachers and supervisors to be
just
a tad more uncomfortable with real sex talk than I had expected
from those who were carrying forth Freud’s legacy of bringing
sexuality and the unconscious into the foreground of Western
culture’s understanding of human nature! My training almost
singularly focused on the patient’s sexual feelings and impulses,
with rare open discussion of the analyst’s sexual feelings and
impulses, particularly in relation to the patient. Under the
rationale
of transforming impulse and action into symbol and meaning
making, we were taught to analyze, sometimes in effect
analyzing
away, sexual material. Although the erotic transference was im-
plicitly elevated, in some quarters even considered the hallmark
of
a complete analysis, it often ended up being unwittingly
relegated
to a nonreal status. With the conceptual shift from libido/drive
model to a more relationally based paradigm, the thinking went
from, “It isn’t me you actually desire but your mother, father,
etcetera” to “It isn’t sex you really want, but love, recognition,

59. attachment, etcetera.”
One can argue that this is precisely what distinguishes psycho-
analysis from other forms of therapy—relating to the patient’s
fantasies, longings, and impulses symbolically, not concretely.
And we know that a SBV is precisely that very failure of
symbol-
ization into psychic equivalence, with the analyst treating
sexual
desire as “real” rather than an entry point for broadening and
deepening analytic exploration. Equally problematic is a
counter-
transferentially driven premature foreclosure of exploration.
This
can take place in many forms, including the use of theory as an
unconscious move on the analyst’s part to defensively defuse
the
reality of intense and sometimes overwhelming sexual feelings,
without adequate internal or interpersonal processing.
T
hi
s
do
cu
m
en
t
is
co
py

60. ri
gh
te
d
by
th
e
A
m
er
ic
an
P
sy
ch
ol
og
ic
al
A
ss
oc
ia
ti

61. on
or
on
e
of
it
s
al
li
ed
pu
bl
is
he
rs
.
T
hi
s
ar
ti
cl
e
is

62. in
te
nd
ed
so
le
ly
fo
r
th
e
pe
rs
on
al
us
e
of
th
e
in
di
vi
du

63. al
us
er
an
d
is
no
t
to
be
di
ss
em
in
at
ed
br
oa
dl
y.
218 GOREN
Green (1995) attributed the de-sexualization of psychoanalysis

64. to American puritanism. I think it is also a natural reaction to
the
increased emotional pressures on the analyst in today’s
relationally
weighted paradigm— one that relies on the analyst’s use of the
self
as an instrument, in a networking culture that presses for the
analyst to be “real,” more self-disclosing, and intimate in social
engagement than in previous eras. The accretion of these factors
makes it difficult for the analyst to balance personal and profes-
sional relatedness, a way of being that is neither
oversexualizing
nor defensively de-sexualizing.
So, how can we learn and help others learn better sexual
communication when in the throes of intense transference coun-
tertransference? Even more challenging, how do we become
more
skilled in recognizing and handling countertransference that is
being dissociated into detachment, hostility, or shaming that ef-
fectively silences exploration or gets enacted in seductive
speech
and manner? For, as Davies (2013) succinctly put it, “Talking
sex
can be as exciting or even more exciting than doing sex” and, I
would add, as potentially harmful when not managed.
A small body of literature is just emerging on handling erotic
countertransference (Davies, 1994, 2013; Gentile, 2013;
Jørstad,
2002; Renn, 2013; Slavin, 2013). Talking of the potential thera-
peutics of playful flirtation, such as what Gentile (2013) and
Renn
(2013) speak of, without more specific guidance and greater
open-
ness regarding countertransference in general can leave a

65. consci-
entious analyst uncertain about how to responsibly proceed with
patients. The challenge for us as analysts, supervisors, and
teachers
is to acknowledge the struggle and to help each other navigate
the
tricky path of respectful yet really open communication about
sex
and sexuality.
We are not only uncomfortable and inadequately trained to deal
with erotic countertransference, but we are also equally uncom-
fortable and minimally trained in the art of dealing with the
intense
feelings of shame, humiliation, frustration, aggression and
hostil-
ity, insatiability, fear, and longing that can accompany or
precip-
itate a reactive erotic transference and/or countertransference.
Left
unexplored, countertransference states that feel threatening,
such
as hostility and disgust, or even more acceptable states, such as
boredom and hopelessness, risk being unconsciously
transformed
into more ego-syntonic states of love and Eros. We need to
target
theory of technique and clinical training on specific ways to
help
an analyst preserve a safe environment for both patient and
ther-
apist. This requires the analyst finding an experiential position
that
allows for “evenly hovering attention” and sovereignty in the
midst of intense erotic, romantic, fearful, and hostile and other
highly charged narcissistically inflected feelings.

66. In our preoccupation with that fateful boundary crossing into
the physical realm, it is easy to miss early warning signs of
SBV
or to recognize emotional abuse that is never physically actu-
alized but, as a form of gas lighting, can have a seriously
damaging, even traumatic, impact on the patient. As therapists,
supervisors, and teachers, we need to be more attentive to those
critical points where ego-dystonic negative and positive coun-
tertransference intersect, the “middle slope” (Arlene Steinberg,
2015, personal communication) when the therapist momentarily
loses grounding, reality testing, and a sense of control as the
guardian of the analysis.
Recommendations and Conclusions
As a psychoanalyst and sex therapist, as someone who has
served on professional ethics committees for decades, I call
upon
my brothers and sisters in the analytic community to think more
about what we really believe constitutes sexual exploitation and
abuse in therapy. In this vein, I think that Division 39 might
consider developing its own set of standards and guidelines or
its
own distinct ethics code— one that takes into consideration the
complexities of boundary crossings, assesses the enduring
power
of transference and countertransference, and, most crucially, ad-
dresses the general issue of posttermination relationships and
takes
a more definitive position on sexual and romantic involvement.
I think we can be more creative in our approach to training and
continuing education on the multiple sticky dynamics that come
into play in analytic practice today. As it now stands,
psychoanal-

67. ysis relies first and foremost on the training analysis and
supervi-
sion to develop the quality of self-awareness and self-
questioning
needed for responsible functioning in the consulting room.
Courses
and workshops on ethics and boundary violations, even when
required, tend to be proforma and too often end up feeling so
morally freighted as to compromise their appeal and utilization.
First we need to put more focus in courses, workshops, and
supervision on intense and challenging transference and
counter-
transference dynamics without the looming specter of SBV,
with its
association to danger and professional failure. This kind of em-
phasis will hopefully be far more welcoming to analysts at all
stages of career.
To develop more comfort and skill in addressing sexuality in
the
consulting room, the atmosphere of any forum needs to be one
that
explicitly attempts to foster freer disclosure of one’s less than
ideal
reactions to patients. Toward this end, I suggest we need to
focus less
on didactic and more on experiential dimensions of
understanding and
learning. Educational formats that privilege theory over
technique,
which we tend to rely on today, can miss the mark of what we
need
more of in our field, particularly with issues of intense erotic
and
related material— honest, open self-confrontation and
disclosure of

68. personal experience and vulnerability. For instance, when
structur-
ing conference panels and classes, instead of relying on the
stan-
dard format of speaker or instructor delivering a paper or
lecture
from the distance of a lectern, we might foster programming
formats that are more experiential and group discussion
oriented.
Finally, I suggest we pay more attention to factors inherent to
psychoanalytic culture and practice that contribute to SBV. The
bond and depth of intimacy between patient and analyst, over
the
course of time, put enormous pressure on the therapist and
patient
to become more personally involved. We hold ourselves to
much
higher goals—personal transformation and fulfillment—than
more
limited, structured types of therapy. But high ideals combined
with
individual risk factors and abstinence requirements can become
combustible in an intractable impasse or when the limits of
what
can be done in a particular analysis are reached. This also
includes
reaching that inevitable moment in the best analyses, what
Celenza
(2010); refers to as the predestined analytic question, “Why
cannot
we be lovers?” Over the decades, one analyst after another has
warned of a certain hubris in the field (Chessick, 2001;
Hoffman,
1998; Slochower, 2003; Weinshel & Renik, 1991) that can blur
the

69. line between ideals and idealization, between our willingness to
“never say die” and our unwillingness to let go.
T
hi
s
do
cu
m
en
t
is
co
py
ri
gh
te
d
by
th
e
A
m
er
ic

70. an
P
sy
ch
ol
og
ic
al
A
ss
oc
ia
ti
on
or
on
e
of
it
s
al
li
ed
pu

71. bl
is
he
rs
.
T
hi
s
ar
ti
cl
e
is
in
te
nd
ed
so
le
ly
fo
r
th
e

72. pe
rs
on
al
us
e
of
th
e
in
di
vi
du
al
us
er
an
d
is
no
t
to
be
di

73. ss
em
in
at
ed
br
oa
dl
y.
219SBV IN PSYCHOANALYSIS: A SEX THERAPIST
SPEAKS
Psychoanalysis is all about human potential and limits. But who
does not love that masked hero Super[wo]man! Perhaps we can
we
take a few lessons from what we tell our patients as well as
what
other treatment modalities have to say on some things. Certainly
our identity can handle it. Our reputation and self-respect
depend
on it.
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is
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80. py
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ia

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83. du
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http://dx.doi.org/10.1080/07351699109533843A Call for More
Talk and Less Abuse in the Consulting Room: One
Psychoanalyst–Sex Therapi ...Psychoanalysis and Sexual Abuse:

85. A Society and Profession in TurmoilHow Analytic Culture and
Practice May Contribute to SBV RiskClinical Training on Sex
in the Consulting RoomRecommendations and
ConclusionsReferences
Self-Reflection Exercise Evaluation Criteria
(10 points maximum for each Self-Reflection assignment)
Self-Reflection Exercises are worth up to 10 points. The criteria
below are for this assignment.
Points for the Self-Reflection Exercises will be awarded as
follows:
9-10 points (of a possible 10 points for the Self-Reflection
assignment)
· Reflection/journal demonstrates a full understanding and
correct use of the concepts and/or strategies as presented in the
Learning Resources.
· Reflection/journal follows directions and includes all
components indicated in the instructions. If requested,
references are included and properly cited.
· Reflection/journal appropriately references personal thoughts
and experiences and makes strong connections between course
material and the student’s life and career.
· Writing demonstrates appropriate informal writing style
utilizing proper grammar, spelling, and punctuation.
7-8 points (of a possible 10 points for the Self-Reflection
assignment)
· Reflection demonstrates a general understanding and correct
use of the concepts and/or strategies as presented in the

86. Learning Resources.
· Reflection follows directions and includes most components
indicated in the instructions. If requested, references are
included and properly cited.
· Reflection/journal sometimes references personal thoughts and
experiences and makes adequate connections between course
material and the student’s life and career.
· Writing sometimes demonstrates appropriate informal writing
style utilizing proper grammar, spelling, and punctuation.
6 or fewer points (of a possible 10 points for the Self-Reflection
assignment)
· Reflection demonstrates a minimal understanding and correct
use of the concepts and/or strategies as presented in the
Learning Resources.
· Reflection does not follow all directions and is missing
components indicated in the instructions. If requested,
references are not included and properly cited.
· Reflection/journal makes inadequate references to personal
thoughts and experiences and few connections between course
material and the student’s life and career.
· Writing is unclear and/or disorganized. Thoughts are not
expressed in a logical manner.
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