Impaired Social Workers/Professionals
Impaired Social Workers/Professionals
- Frederic G. ReamerFrederic G. ReamerRhode Island College
The possibility of practitioner impairment exists in every profession. Stress related to employment, illness or death of family members, marital or relationship problems, financial problems, midlife crises, personal physical or mental illness, legal problems, substance abuse, and professional education can lead to impairment. This article provides an overview of the nature and extent of impairment in social work, practitioners’ coping strategies, responses to impairment, and rehabilitation options and protocols. Particular attention is paid to the problem of sexual misconduct in social workers’ relationships with clients. The author reviews relevant ethical standards and presents a model assessment and action plan for social workers who encounter an impaired colleague.
- Addictions and Substance Use
- Ethics and Values
- Mental and Behavioral Health
- Social Work Profession
Social workers, like all professionals, must be sensitive to the risks of impairment. The subject of impaired professionals began to receive serious attention in the early 1970s. In 1972, for example, the Council on Mental Health of the American Medical Association issued a statement that said that physicians have an ethical responsibility to recognize and report impairment among colleagues. In 1976, a group of attorneys recovering from alcoholism formed Lawyers Concerned for Lawyers to address chemical dependence in the profession, and in 1980, a group of recovering psychologists began a similar group, Psychologists Helping Psychologists (Kilburg, Kaslow, & VandenBos, 1988; Kilburg, Nathan, & Thoreson, 1986; Laliotis & Grayson, 1985; McCrady, 1989; Thoreson, Nathan, Skoria, & Kilburg, 1983; Williams, Pomerantz, Segrist, & Pettibone, 2010).
Social work’s first national acknowledgment of the problem of impaired practitioners came in 1979, when National Association of Social Workers (NASW) issued a public policy statement concerning alcoholism and alcohol-related problems (Commission on Employment and Economic Support of the National Association of Social Workers, 1987). By 1980, a nationwide support group for chemically dependent practitioners, Social Workers Helping Social Workers, had formed. In 1982, NASW formed the Occupational Social Work Task Force, which developed a strategy to deal with impaired NASW members. In 1984, the NASW Delegate Assembly issued a resolution on impairment, and, in 1987, NASW published the Impaired Social Worker Program Resource Book to help members of the profession design programs for impaired social workers. The introduction to the resource book states:
Social workers, like other professionals, have within their ranks those who, because of substance abuse, chemical dependency, mental illness or stress, are unable to function effectively in their jobs. These are the impaired social workers… The problem of impairment is compounded by the fact that the professionals who suffer from the effect of mental illness, stress or substance abuse are like anyone else; they are often the worst judges of their behavior, the last to recognize their problems and the least motivated to seek help. Not only are they able to hide or avoid confronting their behavior, they are often abetted by colleagues who find it difficult to accept that a professional could let his or her problem get out of hand. (p. 6)
Organized efforts to address impaired workers began in the late 1930s and early 1940s after the emergence of Alcoholics Anonymous and in response to the need that arose during World War II to sustain a sound workforce. These early occupational alcoholism programs eventually led, in the early 1970s, to employee assistance programs, designed to address a broad range of problems experienced by workers.
By the early twenty-first century, strategies for dealing with professionals whose work is affected by problems such as substance abuse, mental illness, and emotional stress became more prevalent. Professional associations and informal groups of practitioners formed to discuss the problem of impaired colleagues and to organize efforts to address the problem (Coombs, 2000; Reamer, 1992, 2012; Wynia, 2010).
The Extent and Nature of Impairment
The seriousness of impairment among social workers and the forms it takes vary. Impairment may involve failure to provide competent care or violation of the profession’s ethical standards. It may also take such forms as providing flawed or inferior services to a client, sexual involvement with a client, or failure to carry out professional duties as a result of substance abuse or mental illness. Lamb and colleagues have provided a comprehensive definition of impairment among professionals: “Interference in professional functioning that is reflected in one or more of the following ways: (a) an inability and/or unwillingness to acquire and integrate professional standards into one’s repertoire of professional behavior; (b) an inability to acquire professional skills in order to reach an acceptable level of competency; and (c) an inability to control personal stress, psychological dysfunction, and/or excessive emotional reactions that interfere with professional functioning” (1987, p. 598).
Impairment among social workers and other professionals has various causes. Stress related to employment, illness or death of family members, marital or relationship problems, financial problems, midlife crises, personal physical or mental illness, legal problems, and substance abuse all may lead to impairment (Bissell & Haberman, 1984; Coombs, 2000; Guy, Poelstra, & Stark 1989; Kilburg et al., 1988; Siebert, 2004, 2005; Thoreson, Miller, & Krauskopf, 1989; Zur, 2007). Stress induced by professional education and training can also lead to impairment, stemming from the close supervision and scrutiny students receive, the disruption in students’ personal lives caused by the demands of schoolwork and field placements, and the pressures of students’ academic programs (Lamb et al., 1987).
Mental health professionals encounter special sources of stress that may lead to impairment because their therapeutic role often extends into the nonwork areas of their lives (such as relationships with family members and friends) and because of the lack of reciprocity in relationships with clients (therapists are “always giving”), the often slow and erratic nature of therapeutic progress, and the triggering of therapists’ own issues by therapeutic work with clients (Gilroy, Carroll, & Murra, 2002; Katsavdakis, Gabbard, & Athey, 2004; O’Connor, 2001; Smith & Moss, 2009; Williams et al., 2010; Wood et al., 1985).
There are few empirical estimates of the prevalence of impairment among social workers. Therefore, social workers must look primarily to what is known about impairment in professions that are allied with social work, such as psychology, counseling, and psychiatry. Although we have no precise estimates of the extent of impairment among human service professionals, speculative data are available based on pioneering research that began in the 1980s (Besharov, 1985; Bissell & Haberman, 1984; Bullis, 1995). For example, in the foreword to the Impaired Social Worker Resource Book, published by the Commission on Employment and Economic Support of the National Association of Social Workers, the commission chair states, “Social workers have the same problems as most working groups. Up to 5 to 7% of our membership may have a problem with substance abuse. Another 10 to 15% may be going through personal transitions in their relationships, marriage, family, or their work life” (1987, p. 4). The report goes on to conclude, however, that “there is little reliable information on the extent of impairment among social workers” (p. 6).
The earliest prevalence studies among psychologists suggested a significant degree of distress within the profession. In a study of 749 psychologists, Guy et al. (1989) found that 74.3% reported “personal distress” during the previous three years, and 36.7% of this group believed that their distress decreased the quality of care they provided to clients. Pope, Tabachnick, and Keith-Spiegel report that 62.2% of the members of Division 29 (Psychotherapy) of the American Psychological Association admitted to “working when too distressed to be effective” (1988, p. 993). In their survey of 167 licensed psychologists, Wood and colleagues (1985) found that nearly one-third (32.3%) reported experiencing depression or burnout to an extent that interfered with their work. Wood and colleagues also found that a significant portion of their sample reported being aware of colleagues whose work was seriously affected by drug or alcohol use, sexual overtures toward clients, or depression and burnout. In addition, evidence suggests that psychologists and psychiatrists commit suicide at a rate much higher than the general population (Farber, 1983, cited in Millon, Millon, & Antoni, 1986).
In an important interdisciplinary study, Deutsch (1985) found that more than half her sample of social workers, psychologists, and master’s-level counselors reported significant problems with depression, which can be a correlate of boundary problems. Nearly four-fifths (82%) reported problems with relationships, 11% reported substance abuse problems, and 2% reported suicide attempts.
Coping with Impairment
Unfortunately, relatively little is known about the extent to which impaired human service professionals, especially those who violate boundaries or engage in unethical dual relationships, voluntarily seek help for their problems. Few ambitious studies have been conducted. Guy et al. (1989) found that 70% of the distressed clinical psychologists they surveyed sought some form of therapeutic assistance. One-fourth (26.6%) entered individual psychotherapy, and 10.7% entered family therapy. A small portion of this group participated in self-help groups (3.4%) or were hospitalized (2.2%). Some were placed on medication (4.1%). Exactly 10% of this group temporarily terminated their professional practice.
These findings contrast with those of Wood and colleagues (1985), who found that only 55% of clinicians who reported problems that interfered with their work (sexual overtures toward clients, substance abuse, depression, and burnout) sought help. Two-fifths (42%) of all clinicians surveyed, including impaired and unimpaired professionals, reported having offered help to impaired colleagues at some point or having referred them to therapists, according to Wood and colleagues. Only 7.9% of the sample said they had reported an impaired colleague to a local regulatory body. Two-fifths (40%) were aware of instances in which they believed no action was taken to help an impaired colleague.
We may draw several hypotheses concerning the reluctance of some impaired human service professionals to seek help and the reluctance of their colleagues to confront them about their problems. Professionals may be hesitant to acknowledge impairment within their ranks because they fear how colleagues will react to confrontation and how such confrontation might affect future working relationships among colleagues (Bernard & Jara, 1986; Gilroy et al., 2002; Katsavdakis et al., 2004; McCrady, 1989; O’Connor, 2001; Prochaska & Norcross, 1983; Smith & Moss, 2009; Williams et al., 2010; Wood et al., 1985). As VandenBos and Duthie (1986) note:
The fact that more than half of us have not confronted distressed colleagues even when we have recognized and acknowledged (at least to ourselves) the existence of their problems is, in part, a reflection of the difficulty in achieving a balance between concerned intervention and intrusiveness. As professionals, we value our own right to practice without interference, as long as we function within the boundaries of our professional expertise, meet professional standards for the provision of services, and behave in an ethical manner. We generally consider such expectations when we consider approaching a distressed colleague. Deciding when and how our concern about the well-being of a colleague (and our ethical obligation) supersedes his or her right to personal privacy and professional autonomy is a ticklish matter. (p. 212)
Thoreson and colleagues (1983) also argue that impaired professionals sometimes find it difficult to seek help because of their mythical belief in their infinite power and invulnerability. The involvement of a large number of psychotherapists in private practice exacerbates the problem because of the reduced opportunity for colleagues to observe their unethical conduct, including boundary violations and inappropriate dual relationships (Reamer 2003, 2012).
In Deutsch’s valuable 1985 study, a diverse group of therapists who acknowledged having personal problems gave a variety of reasons for not seeking professional help, including believing that an acceptable therapist was not available, seeking help from family members or friends, fearing exposure and the disclosure of embarrassing confidential information, concern about the amount of effort required and about the cost, having a spouse who was unwilling to participate in treatment, failing to admit the seriousness of the problem, believing that they should be able to work out their problems themselves, and assuming that therapy would not help.
A significant portion of cases involving impaired professionals includes evidence of sexual misconduct. Inappropriate sexual contact and sexualized behavior with clients can take several forms. These include touching body parts (for example, shoulder, arm, hand, leg, knee, face, hair neck), hugging, holding hands, holding a client on one’s lap, engaging in sexual humor, making suggestive remarks or gestures, kissing, exposing one’s genitals, touching breasts, engaging in oral sex, and engaging in sexual intercourse (Celenza, 2007; Reamer, 2012; Samuel & Gorton, 2001; Stake & Oliver, 1991).
Beginning with the Hippocratic Oath, all major helping professions have prohibited sexual relationships with current patients and clients. The Hippocratic Oath obliges physicians to keep “far from all intentional ill-doing and all seduction, and especially from the pleasures of love with women and men” (Dorland’s Medical Dictionary, 1974, p. 715).
A series of empirical studies demonstrates the seriousness and magnitude of boundary violations and inappropriate dual relationships involving professionals’ sexual contact with clients. During a 20-year period, nearly one in five lawsuits (18.5%) against social workers insured through the malpractice insurance program sponsored by the NASW alleged some form of sexual impropriety, and more than two-fifths of insurance payments (41.3%) were the result of claims concerning sexual misconduct (Reamer, 2003).
K. S. Pope (1986) reports on the frequency of successful malpractice claims filed against psychologists during a 10-year period. Although the time period covered by Pope is shorter than the period described for social workers (Reamer, 2003), the similarities are clear. As with social workers, the most frequent claims categories for psychologists during the 10-year period were sexual contact (psychologists, 18.5% of claims; social workers, 18.5% of claims) and treatment error (psychologists, 15.2% of claims; social workers, 18.6% of claims). Approximately 45% of dollars spent during these periods in response to claims against psychologists resulted from claims of sexual contact, and 41% of dollars spent in response to claims against social workers resulted from claims of sexual misconduct.
Schoener and Gonsiorek (1989) estimate that 15 to 16% of male and 2 to 3% of female therapists admit erotic contact with clients. Other national data suggest that 8 to 12% of male counselors or psychotherapists, and 1.7 to 3% of female counselors or psychotherapists, admit having had sexual relationships with a current or former client (Olarte, 1997). In a groundbreaking, comprehensive review of a series of empirical studies focused specifically on sexual contact between therapists and clients, K. S. Pope (1988) found that the aggregate average of reported sexual contact is 8.3 percent by male therapists and 1.7 percent by female therapists. Pope reports that one study (Gechtman & Bouhoutsos, 1985) found that 3.8 percent of male social workers admitted to sexual contact with clients. According to Simon (1999), the reported rate of sexual contact between therapists and clients is generally in the range of 7 percent to 10 percent. Simon cautions that the actual rates are probably higher, because self-report data are known to underestimate actual incidence.
All the available data suggest that the vast majority of cases involving sexual contact between professionals and clients involve a male practitioner and female client (Brodsky, 1986; Celenza, 2007; Bernsen, Tabachnick, & Pope, 1994; Hedges, Hilton, Hilton, & Caudill, 1997; Pope, 1988). Gartrell, Herman, Olarte, Feldstein, and Localio (1986) reported in their groundbreaking survey of psychiatrists that 6.4% of respondents acknowledged sexual contact with their patients; 90% of the offenders were male. Simon (1999) cites data that show that 80% of sexual contacts involving psychiatrists were between male psychiatrists and female patients, 7.6% between male psychiatrists and male patients, 3.5% between female psychiatrists and male patients, and 1.4 percent between female psychiatrists and female patients. Of the 38.4% who were repeaters, none was a female psychiatrist. G. G. Pope (1990, p.193–194) cites a study that found 93% of offending therapists (psychiatrists, marriage counselors, clergy, and social workers) who responded to a large-scale survey were men, and 89% of the victims were women. Although suits against psychiatrists alleging sexual contact tend to be filed more frequently than such suits against psychologists, studies suggest that the prevalence rates for sexual contact with patients by psychiatrists and psychologists are similar. Studies suggest that the prevalence rate for clinical social workers is lower (Celenza, 2007, p. 7–8; Gechtman, 1989).
Olarte provides a succinct profile of the offending therapist:
The composite profile that most frequently emerges from the treatment or consultation with offenders is that the therapist is a middle-aged man who is undergoing some type of personal distress, is isolated professionally, and overvalues his healing capacities. His therapeutic methods tend to be unorthodox; he frequently particularizes the therapeutic relationship by disclosing personal information not pertinent to the treatment, which fosters confusion of the therapeutic boundaries. He is generally well trained, having completed at least an approved training program and at times formal psychoanalytic training. (1997, p. 201)
Brodsky’s overview of offending therapists who are named as defendants in lawsuits contains a number of strikingly similar attributes:
The following characteristics constitute a prototype of the therapist being sued: The therapist is male, middle aged, involved in unsatisfactory relationships in his own life, perhaps in the process of going through a divorce. His patient caseload is primarily female. He becomes involved with more than one patient sexually, those selected being on the average 16 years younger than he is. He confides his personal life to the patient, implying to her that he needs her, and he spends therapy sessions soliciting her help with his personal problems. The therapist is a lonely man, and even if he works in a group practice, he is somewhat isolated professionally, not sharing in close consultation with his peers. He may have a good reputation in the psychological or psychiatric community, having been in practice for many years. He tends to take cases through referral only. He is not necessarily physically attractive, but there is an aura of power or charisma about him. His lovemaking often leaves much to be desired, but he is quite convincing to the patient that it is he above all others with whom she needs to be making love (1986, p. 157–158).
Brodsky (1986) also describes other sexually abusive therapists, including those who tend to be inexperienced and in love with one particular client, and therapists with a personality disorder (typically antisocial personality disorder) who manipulate clients into believing that the therapists should be trusted and that they have the clients’ best interest at heart.
Celenza (2007, p. 11, 29–38) studied a sample of mental health professionals who engaged in sexual misconduct and found a number of common precursors related primarily to the practitioner’s personality, life circumstances, past history, and the transference/countertransference dynamics of this particular therapist–client pair. More specifically, Calenza found that clinicians who manifest certain traits are more likely to engage in sexual misconduct:
Longstanding narcissistic vulnerability. Therapists reported a lifelong struggle with a sense of unworthiness, inadequacy, or outright feelings of failure.
Grandiose (covert) rescue fantasies. Therapists presented a mild-mannered, self-effacing, and humble exterior that hid underlying (and unchallenged) beliefs in powers of rescue and omnipotence.
Intolerance of negative transference. Often as a result of fragile self-esteem, some therapists have difficulty tolerating and exploring disappointments, frustrations, and criticisms that the client may have about the services she or he is receiving.
Childhood history of emotional deprivation and sexualized overstimulation. Some therapists reported sexualization in their relationship with a primary caregiver (usually the mother), often in the form of overstimulation of the child in a sexualized manner rather than outright sexual abuse.
Family history of covert and sanctioned boundary transgressions. Some therapists’ families showed evidence of high moralism accompanied by hypocrisy, for example, in the form of marital infidelity or fraudulent financial activity.
Unresolved anger toward authority figures. Some therapists appeared to engage in sexual misconduct as a way to rebel against the authority of their profession and as a result of an underlying desire to break the rules, perhaps because of anger toward an authoritarian parent.
Restricted awareness of fantasy (especially hostile/aggressive). Many therapists, especially those who felt intense guilt and remorse, were unable to admit to or access hateful or desirous wishes except in conventional or muted ways. These therapists had difficulty perceiving aggression in themselves or others.
Transformation of countertransference hate to countertransference love. Some therapists had difficulty tolerating their own aggression and perceiving themselves as depriving or non-nurturing with clients. They harbored the unrealistic belief that they should love and help every client.
A small number of practitioners named in ethics complaints and lawsuits try to defend their sexual contact with clients (Gutheil & Brodsky, 2008; Reamer, 2003; Schutz, 1982). One argument mounted by some clinicians accused of misconduct is that the sexual relationship was independent of the therapeutic relationship. In these instances, the defendant-therapist usually argues that he and the client were able to separate their sexual involvement from their professional relationship. As Schutz suggests in one of the earliest discussions of this phenomenon, however, this argument “has not been a very successful defense, since courts are reluctant to accept such a compartmentalized view of human relationships. A therapist attempting to prove the legitimacy of sexual relations between himself and a patient by establishing that two coterminous-in-time but utterly parallel relations existed has a difficult task” (1982, p. 35).
Sexual misconduct by therapists is now a criminal offense in a number of states (Celenza, 2007). Some formerly licensed clinicians have been sentenced to prison following conviction in criminal court.
Also, state licensing boards have addressed a significant number of sexual misconduct cases in response to formal complaints. Because many licensing board websites feature disciplinary reports, anyone with Internet access can review considerable detail about clinicians’ sexual misconduct and any sanctions imposed by licensing boards.
Further, many clinicians have been sued in civil court by clients or former clients who allege that they were harmed by therapists’ sexual exploitation. Other clinicians have had formal complaints filed against them with national professional associations (such as the NASW) of which they are members.
Sexual Misconduct: Causal Factors
A large percentage of clinical practitioners report having felt attracted to their clients—although most do not act on this attraction (Pope et al., 1988). More than half of a statewide sample of clinical social workers (52.4%)—two-thirds of whom were women—reported having felt sexually attracted to a client (Jayaratne, Croxton, & Mattison, 1997).
The literature offers diverse theories about the causes of, and factors associated with, practitioner sexual misconduct. For example, Simon (1999), a pioneer in research on practitioner misconduct, argues that boundary violations are a function of the nature of the client’s clinical issues, type of treatment, status of the therapeutic alliance (whether it is strong or weak, functional or dysfunctional), and personality of the therapist, combined with his or her training and experience.
Smith and Fitzpatrick (1995) highlight the importance of the clinician’s training and theoretical orientation. They argue that human service professionals must recognize significant differences among different ideological orientations and schools of thought in psychotherapy in determining whether a sexual boundary has been crossed.
Several authors believe that practitioners who engage in sexual misconduct can be categorized conceptually. Twemlow and Gabbard (1989) characterize therapists who fall in love with clients—a particular subgroup of clinicians who become sexually involved with clients—as lovesick therapists. Lovesickness includes several key elements: emotional dependence; intrusive thinking, whereby the therapist thinks about the client almost constantly; physical sensations, such as buoyancy or pounding pulse; a sense of incompleteness, of feeling less than whole when away from the client; an awareness of the social proscription of such love, which seems to intensify the couple’s longing for each other; and an altered state of consciousness that fosters impaired judgment on the part of the therapist when in the presence of the loved one.
According to Schoener (1995), he and his colleagues base their widely cited classification scheme—which includes a broader range of offending therapists—on empirical evidence gathered from psychological and psychiatric examinations of sexually exploitative therapists. These clinical clusters (the italicized terminology is Schoener’s) include:
Psychotic and severe borderline disorders. While relatively few in number, these professionals have difficulties with boundaries because of problems with both impulse control and thinking. They are often aware of current ethical standards but have difficulty adhering to them because of their poor reality testing and judgment. Some practitioners manifest symptoms of manic disorders. Most typically these are practitioners who have been diagnosed with mania, go off medication, and become quite impulsive.
Sociopaths and severe narcissistic personality disorders. These are self-centered exploiters who cross various boundaries when it suits them. They tend to be calculating and deliberate in their abuse of their clients. They often manipulate the treatment by “blurring the professional boundaries with inappropriate personal disclosure that enhances and idealizes transference, and by manipulating the length or the time of the sessions to facilitate the development of a sexual relationship with the client. . . . If caught, they might express remorse and agree to rehabilitation to protect themselves or their professional standing, but they will show minimal or no character change through treatment” (Olarte, 1997, p. 205).
Impulse-control disorders. This group includes practitioners with a wide range of paraphilias (sexual disorders in which unusual fantasies or bizarre acts are necessary for sexual arousal) and other impulse-control disorders. These professionals often have impulse-control problems in other areas of their lives. They are typically aware of current ethical standards, but these do not serve as a deterrent. These practitioners often fail to acknowledge the harm that their behavior does to their victims, and they show little remorse.
Chronic neurotic and isolated. These practitioners are emotionally needy on a chronic basis and meet many needs through their relationships with clients. They may suffer from longstanding problems with depression, low self-esteem, social isolation, and lack of confidence. At times, these practitioners disclose personal information to clients inappropriately. Typically, they deny engaging in misconduct or justify the unethical behavior as their therapeutic technique designed to enhance their suffering client’s self-esteem. They may also blame the client’s claims on the client’s pathology. Such practitioners are often repeat offenders.
Situational offenders. These therapists are generally healthy with a good practice history, and they are free of boundary problems, but a situational breakdown in judgment or control has occurred in response to some life crisis or loss. These practitioners are generally aware of current ethical standards. According to Olarte, “Their sexual contact with a client is usually an isolated or limited incident. Frequently at the time of the boundary violation, these therapists are suffering from personal or situational stresses that foster a slow erosion of their professional boundaries. They most often show remorse for their unethical behavior, frequently stop such violations on their own, or seek consultation with peers” (1997, p. 204).
Naïve. These therapists have difficulty understanding and operating within professional boundaries because they suffer from deficits in social judgment, not pathology. Their difficulties stem in part from their lack of knowledge of current ethical standards and their confusion about the need to separate personal and professional relationships.
In contrast to this framework, Simon (1999) offers a typology that includes somewhat different clinical dimensions. Simon places vulnerable therapists in five categories (the italicized terminology is Simon’s):
Character disordered. Therapists diagnosed with symptoms of borderline, narcissistic, or antisocial personality disorder.
Sexually disordered. Therapists diagnosed with frotteurism (recurrent intense sexual urges and sexually arousing fantasies in regard to a nonconsenting person), pedophilia, or sexual sadism.
Incompetent. Therapists who are poorly trained or have persistent boundary blind spots.
Impaired. Therapists who have serious problems with alcohol, drugs, or mental illness.
Situational reactors. Therapists who are experiencing marital discord, loss of important relationships, or a professional crisis.
Based on his extensive experience with vulnerable and offending therapists, Simon (1999) argues that boundary violations are often progressive and follow a sequence, or “natural history,” that leads ultimately to a therapist–client sexual relationship. Here is a common sequence in an office-based one-on-one clinical relationship:
The therapist’s neutrality gradually erodes. The therapist begins to take special interest in the client’s issues and life circumstances.
Boundary violations begin between the chair and the door. As the client is leaving the office, and both client and worker are standing, the therapist and client may discuss personal issues that are not part of the more formal therapeutic conversation.
Therapy becomes socialized. More time is spent discussing nontherapy issues.
The therapist discloses confidential information about other clients. The therapist begins to confide in the client, communicating to the client that she is special.
Therapist self-disclosure begins. The therapist shares information about his own life, perhaps concerning marital or relationship problems.
Physical contact begins (for example, touching, hugs, kisses). Casual physical gestures convey to the client that the therapist has warm and affectionate feelings toward her.
Therapist gains control over client. The client begins to feel more and more dependent on the therapist, and the therapist exerts more and more influence in the client’s life.
Extratherapeutic contacts occur. The therapist and client may meet for lunch or for a drink.
Therapy sessions are longer. The customary 50-minute session is extended because of the special relationship.
Therapy sessions are rescheduled for the end of day. To avoid conflict with other clients’ appointments, the therapist arranges to see the client as the day’s final appointment.
The therapist stops billing the client. The emerging intimacy makes it difficult for the therapist to charge the client for the time they spend together.
Dating begins. The therapist and client begin to schedule times when they can be together socially.
Therapist–client sex occurs.
Gutheil and Gabbard agree with Simon that sexual misconduct usually begins with relatively minor boundary violations “which often show a crescendo pattern of increasing intrusion into the patient’s space that culminates in sexual contact” (1993, p. 188). They caution, however, that not all boundary crossings, or even boundary violations, lead to or represent evidence of sexual misconduct.
Some authors have expressed concern about a tendency among theorists to blame the victim when exploring sexual relationships between therapists and clients. Celenza, for example, traces the evolution of concern about sexual misconduct and asserts that “up through much of the last century the focus was on the male professional as either a victim of manipulation, or on mutual responsibility for what had happened” (2007, p. xv).
One common theme in the literature on sexual misconduct is the inadequacy of professional education and training. Comprehensive surveys of practicing clinicians and trainees (Gartrell et al., 1987; Olarte, 1997; Pope, Keith-Spiegel, & Tabachnick, 1986) have found that most cite training that is inadequate for helping them deal constructively with their sexual attraction to their clients.
Responding to Impairment
It is important for social workers to design ways to prevent impairment and respond to impaired colleagues. They must be knowledgeable about the indicators and causes of impairment so that they can recognize problems that colleagues may be experiencing. Social workers must also be willing to confront impaired colleagues constructively, offer assistance and consultation, and, if necessary as a last resort, refer the colleague to a supervisor or local regulatory or disciplinary body (such as a chapter ethics committee of NASW or a licensing board).
To the profession’s credit, in 1992, the president of NASW created the Code of Ethics Review Task Force, which proposed adding new principles to the code on the subject of impairment. The approved additions became effective in 1994 and were then modified slightly and incorporated as standards in the current code (NASW, 2008):
Standard 4.05(a). Social workers should not allow their own personal problems, psychosocial distress, legal problems, substance abuse, or mental health difficulties to interfere with their professional judgment and performance or to jeopardize the best interests of people for whom they have a professional responsibility.
Standard 4.05(b). Social workers whose personal problems, psychosocial distress, legal problems, substance abuse, or mental health difficulties interfere with their professional judgment and performance should immediately seek consultation and take appropriate remedial action by seeking professional help, making adjustments in workload, terminating practice, or taking any other steps necessary to protect clients and others.
Standard 2.09(a). Social workers who have direct knowledge of a social work colleague’s impairment that is due to personal problems, psychosocial distress, substance abuse, or mental health difficulties and that interferes with practice effectiveness should consult with that colleague when feasible and assist the colleague in taking remedial action.
Standard 2.09(b). Social workers who believe that a social work colleague’s impairment interferes with practice effectiveness and that the colleague has not taken adequate steps to address the impairment should take action through appropriate channels established by employers, agencies, NASW, licensing and regulatory bodies, and other professional organizations.
Relatively little research has been conducted on the effectiveness of efforts to rehabilitate impaired professionals who engage in ethical misconduct (Celenza, 2007; Gutheil & Brodsky, 2008; Jorgenson, 1995; Sonnenstuhl, 1989; Trice & Beyer, 1984). Many investigations have serious methodological limitations; few studies control adequately for extraneous factors that may account for changes over time in practitioners’ attitudes and behavior.
Beginning in the early 2000s, several organized efforts have tried to identify and address the problems of impaired professionals and ethical misconduct. A growing consensus was that a model strategy for addressing impairment among professionals should have several components (Celenza, 2007; Gabriel, 2005; Reamer, 2012; Schoener & Gonsiorek, 1989; Sonnenstuhl, 1989; VandenBos & Duthie, 1986). First, human service professionals need adequate means for identifying impaired colleagues. Professionals must be willing to assume responsibility for acknowledging impairment among colleagues. And as Lamb and colleagues (1987) note, it certainly would help to develop reasonably objective measures of what constitutes failure to live up to professional standards, incompetent skills, and impaired professional functioning.
Second, a professional who spots a colleague who may be impaired should first speculate about the causes and then proceed with what Sonnenstuhl (1989) describes as “constructive confrontation.” Third, the practitioner must decide whether to help the impaired colleague identify ways to seek help voluntarily or to refer the colleague to a supervisor or local regulatory body (such as a licensing board or professional association’s ethics committee).
Assuming a rehabilitation plan is appropriate to the situation, the impaired practitioner’s colleagues, supervisor, or local regulatory body should make specific recommendations. The possibilities include close supervision, personal psychotherapy, or other appropriate treatment (for example, substance-abuse treatment). In some cases, a licensing board or professional association may need to impose some type of sanction, such as censure, probation, limitations on the clinician’s practice (for example, concerning type of clientele served or practice setting), suspension, license revocation, or termination of employment.
With specific regard to treatment that follows the filing and processing of a formal complaint, Schoener (1995) argues that, ideally, a comprehensive assessment of the practitioner would be conducted by a licensing or regulatory body and would involve several steps, including:
Gathering data about the practitioner’s professional training, professional work history, and personal history (including noteworthy ups and downs), and the nature of the practice-related complaint (boundary violation)
Generating hypotheses about causal factors that may be involved in the boundary violation
Formulating a rehabilitation plan, when feasible
Coordinating the rehabilitation plan with the licensing board, professional association, and practitioner’s employer
Implementing the corrective action (for example, psychotherapy, supervision, consultation, continuing education) and, when necessary, appropriate sanctions (for example, license suspension or revocation, expulsion from professional association)
Evaluating the practitioner’s progress with regard to the possibility of permitting reentry to practice and the profession.
Gabriel (2005) argues that a comprehensive rehabilitation process may take three to five years, with yearly evaluations. Often, interviewing the original victim or complainant is essential. According to Schoener, “This often proves invaluable. Beyond helping us avoid being taken in by intentional distortions on the part of the practitioner being evaluated, it provides a much more complete picture of the events in question. Even a completely honest, nondefensive professional who is being cooperative does not know all that happened. Each party experienced the events differently” (1995, p. 98).
Schoener (1995) believes that a formal assessment of an exploitative practitioner should not be conducted, or a rehabilitation plan developed, unless: (a) the practitioner admits wrongdoing and understands that the client suffered harm, (b) the practitioner believes that he or she has a problem that requires rehabilitation, (c) the practitioner is willing to agree to the assessment and realizes that its outcome may not be favorable, and (d) the essential facts of the case are not in dispute. Once the practitioner has completed the rehabilitation plan, those responsible for overseeing it must be able to answer yes to two questions: “To a reasonable degree of psychiatric or psychological certainty, have the problems you were treating been fixed or resolved?” and “Would you have any qualms whatsoever if your spouse or child went to see this person for individual therapy?”
Studies have shown that ambitious, skilled treatment of offending practitioners can be effective (Gutheil & Brodsky, 2008; Simon, 1999). Prospects are not encouraging for practitioners who have been diagnosed with serious personality disorders or paraphilias, however, or for those who are deemed incompetent (Schoener, 1995; Simon, 1999).
Although some cases of impairment must be dealt with through formal adjudication and disciplinary procedures, many cases can be handled primarily by arranging therapeutic or rehabilitative services for distressed practitioners. For example, state chapters of NASW can enter into agreements with local employee assistance programs, to which impaired members can be referred.
As social workers increase the attention they pay to the problem of impairment, they must be careful to avoid assigning all responsibility to the practitioners themselves. Although psychotherapy and individually focused rehabilitative efforts are appropriate, social workers must also address the environmental stresses and structural factors that can cause impairment. Distress experienced by social workers is often the result of the unique challenges in a profession for which resources are inadequate. Caring social workers who are overwhelmed by clients’ chronic problems of poverty, substance abuse, child abuse and neglect, hunger and homelessness, and mental illness are prime candidates for high degrees of stress and burnout. Insufficient funding, unpredictable political support, and public skepticism of social workers’ efforts often lead to low morale and high stress (Jayaratne & Chess, 1984; Johnson & Stone, 1986; Koeske & Koeske, 1989; Leiter & Maslach, 2005; Maslach, 2003). Thus, in addition to responding to the individual problems of impaired colleagues, social workers must confront the environmental and structural problems that can cause the impairment in the first place. This comprehensive effort to confront the problem of impaired practitioners can also help to reduce unethical behavior and professional misconduct in social work.
- Bernard, J. L., & Jara, C. S. (1986). The failure of clinical psychology students to apply understood ethical principles. Professional Psychology: Research and Practice, 17, 316–321.
- Bernsen, A., Tabachnick, B. G., & Pope, K. S. (1994). National survey of social workers’ sexual attraction to their clients: Results, implications, and comparison to psychologists. Ethics and Behavior, 4, 369–388.
- Besharov, D. J. (1985). The vulnerable social worker: Liability for serving children and families. Silver Spring, MD: NASW.
- Bissell, L., & Haberman, P. W. (1984). Alcoholism in the professions. New York, NY: Oxford University Press.
- Brodsky, A. M. (1986). The distressed psychologist: Sexual intimacies and exploitation. In R. R. Kilburg, P. E. Nathan, & R. W. Thoreson (Eds.), Professionals in distress: Issues, syndromes, and solutions in psychology (pp. 153–171). Washington, DC: American Psychological Association.
- Bullis, R. K. (1995). Clinical social worker misconduct. Chicago, IL: Nelson-Hall.
- Celenza, A. (2007). Sexual boundary violations: Therapeutic, supervisory, and academic contexts. Lanham, MD: Aronson.
- Coombs, R. H. (2000). Drug-impaired professionals. Cambridge, MA: Harvard University Press.
- Deutsch, C. (1985). A survey of therapists’ personal problems and treatment. Professional Psychology: Research and Practice, 16, 305–315.
- Dorland’s Medical Dictionary (25th ed.). (1974). Philadelphia, PA: Saunders.
- Farber, B. A. (Ed.). (1983). Stress and burnout in the human service professions. New York, NY: Pergamon.
- Gabriel, L. (2005). Speaking the unspeakable: The ethics of dual relationships in counseling and psychotherapy. New York, NY: Routledge.
- Gartrell, N., Herman, J., Olarte, S., Feldstein, M., & Localio, R. (1986). Psychiatrist-patient sexual contact: Results of a national survey. American Journal of Psychiatry, 143, 1126–1131.
- Gartrell, N., Herman, J., Olarte, S., Feldstein, M., & Localio, R. (1987). Reporting practices of psychiatrists who knew of sexual misconduct by colleagues. American Journal of Orthopsychiatry, 57, 287–295.
- Gechtman, L. (1989). Sexual contact between social workers and their clients. In G. O. Gabbard, (Ed.), Sexual exploitation in professional relationships (pp. 27–38). Washington, DC: American Psychiatric Press.
- Gechtman, L., & Bouhoutsos, J. C. (1985). Sexual intimacy between social workers and clients. Paper presented at the annual meeting of the Society for Clinical Social Workers, University City, CA.
- Gilroy, P. J., Carroll, L., & Murra, J. (2002). A preliminary survey of counseling psychologists’ personal experiences with depression and treatment. Professional Psychology, Research, and Practice, 33, 402–407.
- Gutheil, T. G., & Brodsky, A. (2008). Preventing boundary violations in clinical practice.New York, NY: Guilford.
- Gutheil, T. G., & Gabbard, G. O. (1993). The concept of boundaries in clinical practice: Theoretical and risk-management dimensions. American Journal of Psychiatry, 150, 188–196.
- Guy, J. D., Poelstra, P. L., & Stark, M. (1989). Personal distress and therapeutic effectiveness: National survey of psychologists practicing psychotherapy. Professional Psychology: Research and Practice, 20, 48–50.
- Hedges, L. E., Hilton, R., Hilton, V. W., & Caudill, O. B., Jr. (Eds.). (1997). Therapists at risk: Perils of the intimacy of the therapeutic relationship. Northvale, NJ: Aronson.
- Jayaratne, S., & Chess, W. A. (1984). Job satisfaction, burnout, and turnover: A national study. Social Work, 29, 448–455.
- Jayaratne, S., Croxton, T., & Mattison, D. (1997). Social work professional standards: An exploratory study. Social Work, 42, 187–199.
- Johnson, M., & Stone G. L. (1986). Social workers and burnout. Journal of Social Work Research, 10, 67–80.
- Jorgenson, L. M. (1995). Rehabilitating sexually exploitative therapists: A risk-management perspective. Psychiatric Annals, 25, 118–122.
- Katsavdakis, K. A., Gabbard, G. O., & Athey, G. I. (2004). Profiles of impaired health professionals. Bulletin of the Menninger Clinic, 68, 60–72.
- Kilburg, R. R., Kaslow, F. W., & VandenBos, G. R. (1988). Professionals in distress. Hospital and Community Psychiatry, 39, 723–725.
- Kilburg, R. R., Nathan, P. E., & Thoreson, R. W. (Eds.). (1986). Professionals in distress: Issues, syndromes, and solutions in psychology. Washington, DC: American Psychological Association.
- Koeske, G. F., & Koeske, R. D. (1989). Work load and burnout: Can social support and perceived accomplishment help? Social Work, 34, 243–248.
- Laliotis, D. A., & Grayson, J. H. (1985). Psychologist heal thyself: What is available for the impaired psychologist. American Psychologist, 40, 84–96.
- Lamb, D. H., Presser, N. R., Pfost, K. S., Baum, M. C., Jackson, V. R., & Jarvis, P. A. (1987). Confronting professional impairment during the internship: Identification, due process, and remediation. Professional Psychology: Research and Practice, 18, 597–603.
- Leiter, M. P, & Maslach, C. (2005). Banishing burnout: Six strategies for improving your relationship with work. San Francisco, CA: Jossey-Bass.
- Maslach, C. (2003). Job burnout: New directions in research and intervention. Current Directions in Psychological Science, 12, 189–192.
- McCrady, B. S. (1989). The distressed or impaired professional: From retribution to rehabilitation. Journal of Drug Issues, 19, 337–349.
- Millon, T., Millon, C., & Antoni, M. (1986). Sources of emotional and mental disorder among psychologists: A career development perspective. In R. R. Kilburg, P. E. Nathan, & R. W. Thoreson (Eds.), Professionals in distress: Issues, syndromes, and solutions in psychology (pp. 119–134). Washington, DC: American Psychological Association.
- National Association of Social Workers (NASW). (2008). NASW code of ethics. Washington, DC: Author.
- Commission on Employment and Economic Support of the National Association of Social Workers. (1987). Impaired Social Worker Program Resource Book. Silver Spring, MD: National Association of Social Workers.
- O’Connor, M. F. (2001). On the etiology and effective management of professional distress and impairment among psychologists. Professional Psychology, Research, and Practice, 32, 345–350.
- Olarte, S. W. (1997). Sexual boundary violations. In Hatherleigh guide to ethics in therapy (pp. 195–209). New York, NY: Hatherleigh.
- Pope, G. G. (1990). Abuse of psychotherapy: Psychotherapist-patient intimacy. Psychotherapy and Psychosomatics, 53, 191–198.
- Pope, K. S. (1986). New trends in malpractice cases and changes in APA’s liability insurance. Independent Practitioner, 6, 23–26.
- Pope, K. S. (1988). How clients are harmed by sexual contact with mental health professionals: The syndrome and its prevalence. Journal of Counseling and Development, 67, 222–226.
- Pope, K. S., Keith-Spiegel, P., & Tabachnick, B. G. (1986). Sexual attraction to clients: The human therapist and the (sometimes) inhuman training system. American Psychologist, 41, 147–148.
- Pope, K. S., Tabachnick, B. G., & Keith-Spiegel, P. (1988). Good and bad practice in psychotherapy: National survey of beliefs of psychologists. Professional Psychology: Research and Practice, 19, 547–552.
- Prochaska, J. O., & Norcross, J. C. (1983). Psychotherapists’ perspectives on treating themselves and their clients for psychic distress. Professional Psychology: Research and Practice, 14, 642–655.
- Reamer, F. G. (1992). The impaired social worker. Social Work, 37, 165–170.
- Reamer, F. G. (2003). Social work malpractice and liability: Strategies for prevention (2nd ed.). New York, NY: Columbia University Press.
- Reamer, F. G. (2012). Boundary issues and dual relationships in the human services. New York, NY: Columbia University Press.
- Samuel, S. E., & Gorton, G. E. (2001). Sexual exploitation: An extreme of professional deception. American Journal of Forensic Psychiatry, 22, 63–81.
- Schoener, G. R. (1995). Assessment of professionals who have engaged in boundary violations. Psychiatric Annals, 25, 95–99.
- Schoener, G. R., & Gonsiorek, J. C. (1989). Assessment and development of rehabilitation plans for the therapist. In G. R. Schoener, J. H. Milgrom, J. C. Gonsiorek, E. T. Luepker, & R. M. Conroe (Eds.), Psychotherapists’ sexual involvement with clients: Intervention and prevention (pp. 401–420). Minneapolis, MN: Walk-In Counseling Center.
- Schoener, G. R., Milgrom, J. H., Gonsiorek, J. C., Luepker, E. T., & Conroe, R. M. (Eds.). (1989). Psychotherapists’ sexual involvement with clients: Intervention and prevention. Minneapolis, MN: Walk-In Counseling Center.
- Schutz, B. M. (1982). Legal liability in psychotherapy. San Francisco, CA: Jossey-Bass.
- Siebert, D. (2004). Depression in North Carolina social workers: Implications for practice and research. Social Work Research, 28, 30–40.
- Siebert, D. (2005). Help seeking for AOD misuse among social workers: Patterns, barriers, and implications. Social Work, 50, 65–75.
- Simon, R. I. (1999). Therapist-patient sex: From boundary violations to sexual misconduct. Forensic Psychiatry, 22, 31–47.
- Smith, D. & Fitzpatrick, M. (1995). Patient-therapist boundary issues: An integrative review of theory and research. Professional Psychology: Research and Practice, 26, 499–506.
- Smith, P. L., & Moss, S. B. (2009). Psychologist impairment: What is it, how can it be prevented, and what can be done to address it? Clinical Psychology: Science and Practice, 16, 1–15.
- Sonnenstuhl, W. J. (1989). Reaching the impaired professional: Applying findings from organizational and occupational research. Journal of Drug Issues, 19, 533–539.
- Stake, J. E., & Oliver, J. (1991). Sexual contact and touching between therapist and client: A survey of psychologists’ attitudes and behavior. Professional Psychology: Research and Practice, 22, 297–307.
- Thoreson, R. W., Miller, M., & Krauskopf, C. J. (1989). The distressed psychologist: Prevalence and treatment considerations. Professional Psychology: Research and Practice, 20, 153–158.
- Thoreson, R. W., Nathan, P. E., Skoria, J. K., & Kilburg, R. R. (1983). The alcoholic psychologist: Issues, problems, and implications for the profession. Professional Psychology: Research and Practice, 14, 670–684.
- Trice, H. M., & Beyer, J. M. (1984). Work-related outcomes of the constructive confrontation strategy in a job-based alcoholism program. Journal of Studies on Alcohol, 45, 393–404.
- Twemlow, S. W., & Gabbard, G. O. (1989). The love-sick therapist. In G. O. Gabbard (Ed.), Sexual exploitation in professional relationships (pp. 71–87). Washington, DC: American Psychiatric Press.
- VandenBos, G. R., & Duthie, R. F. (1986). Confronting and supporting colleagues in distress. In R. R. Kilburg, P. E. Nathan, & R. W. Thoreson (Eds.), Professionals in distress: Issues, syndromes, and solutions in psychology (pp. 211–231). Washington, DC: American Psychological Association.
- Williams, B. E., Pomerantz, A. M., Segrist, D. J., & Pettibone, J. C. (2010). How impaired is too impaired? Ratings of psychologist impairment by psychologists in independent practice. Ethics & Behavior, 20, 149–160.
- Wood, B. J., Klein, S., Cross, H. J., Lammers, C. J., & Elliott, J. K. (1985). Impaired practitioners: Psychologists’ opinions about prevalence, and proposals for intervention. Professional Psychology: Research and Practice, 16, 843–850.
- Wynia, M. K. (2010). The role of professionalism and self-regulation in detecting impaired or incompetent physicians. Journal of the American Medical Association, 304, 210–212.
- Zur, O. (2007). Boundaries in psychotherapy: Ethical and clinical explorations. Washington, DC: American Psychological Association.