Please no plagiarism and make sure you are able to access all resources on your own before you bid. Main references come from Murray, C., Pope, A., & Willis, B. (2017) and/or American Psychological Association (2014).  Assignments should adhere to graduate-level writing and be free from writing errors. Please follow the instructions to get full credit. I need this completed by 03/07/2020 at 4pm. 

Assignment 1 – Week 2

Assessment and Intervention

As you may recall from your theories courses earlier in your program, there are many counseling theories and perspectives upon which to base case conceptualization and treatment. You also may recall that theory integration and modification are important skills for marriage, couple, and family counselors. Your course text presents this kind of theory integration in a model called the integrative couples’ model.

For this week’s Assignment, you apply the integrative couples model to a case study and use it to plan assessments and interventions for the couple in the case. Base your responses on the following case study:

Stella, age 34, and Dan, age 37, present for couples counseling with two primary complaints. First, the partners report that they have been fighting frequently, often several times a day, since their first child was born eight months ago. Second, both partners report that they are “very dissatisfied” with their sexual relationship. Stella reports, and Dan agrees, “We’ve probably had sex about three times since I first got pregnant.” Both partners report that they just lack the interest and energy to be sexually intimate with each other.

Stella and Dan report that they have been married for 3 years. They both acknowledge that their sex life “wasn’t great” even before Stella became pregnant, but they report that they previously were not concerned about that aspect of their relationship. However, as Dan says, “Now that we’re fighting in addition to not having sex, it just seems like there’s not much there for us in our relationship at all.” Both partners report that they would like to see their sexual relationship, in addition to other aspects of their marriage, improve.

The Assignment (2- to 3-page paper):

· Explain why the integrative couples’ model of sexuality counseling is an appropriate approach for the case study.

· Describe the assessment you would conduct based on the model, including two key components of the assessment. Explain why you would use this assessment.

· Finally, in light of possible information, you might gain from the assessment, describe two interventions you might use with the client based on the integrative couples’ model and explain why.

Support your Assignment with specific references to all resources used in its preparation. You are to provide a reference list for all resources, including those in the Learning Resources for this course.

Required Resources

· Course Text: Murray, C., Pope, A., & Willis, B. (2017). Sexuality counseling: Theory, research, and practice. Thousand Oaks, CA: Sage

· Chapter 2, “Assessment in Sexuality Counseling”

· Chapter 3, “General Interventions and Theoretical Approaches to Sexuality Counseling”

· Article: Goren, E. R. (2017). A call for more talk and less abuse in the consulting room: One psychoanalyst–sex therapist’s perspective. Psychoanalytic Psychology, 34(2), 215–220. Retrieved from the Walden Library databases.

· Article: Hendricks, C. B., Bradley, L. J., & Robertson, D. L. (2015). Implementing multicultural ethics: Issues for family counselors. The Family Journal, 23(2), 190–193. Retrieved from the Walden Library databases.

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, family counselors find themselves working with clients

who are increasingly diverse; that is, vastly different from their

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,

TX, USA

Corresponding Author:

C. Bret Hendricks, Department of Educational Psychology and Leadership,

Texas Tech University, 3008-18th, Lubbock, TX 79409, USA.

Email: bret.hendricks@ttu.edu

The Family Journal: Counseling and
Therapy for Couples and Families
2015, Vol. 23(2) 190-193
ª The Author(s) 2015
Reprints and permission:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/1066480715573251
tfj.sagepub.com

http://www.sagepub.com/journalsPermissions.nav

http://tfj.sagepub.com

http://crossmark.crossref.org/dialog/?doi=10.1177%2F1066480715573251&domain=pdf&date_stamp=2015-03-20

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

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-

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).

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

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.

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

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.

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

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

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.

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-

shifting perspectives of a multicultural society.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to

the research, author

ship, 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.

References

Anderson, P., Lawton, L., Rexeisen, R., & Hubbard, A. (2006). Short-

term study abroad and intercultural sensitivity: A pilot study. Inter-

national Journal of Intercultural Relations, 30, 457–469.

Auger, R. W. (2004). What we don’t know CAN hurt us: Mental

health counselors’ implicit assumptions about human nature. Jour-

nal of Mental Health Counseling, 26, 13–24.

Boysen, G. A. (2010). Integrating implicit bias into counselor educa-

tion. Counselor Education and Supervision, 49, 210–227.

Boysen, G. A., & Vogel, D. L. (2008). The relationship between

level of training, implicit bias, and multicultural competency

among counselor trainees. Training and Education in Professional

Psychology, 2, 103–110.

Cannon, E.P. (2005). The need to infuse multicultural competence into

master’s level community counseling internship. In G. R. Walz &

R. K. Yep (Eds.), VISTAS: Compelling perspectives in counseling

(pp. 153–159). Alexandria, VA: American Counseling Association.

Cook-Greuter, S., & Soulen, J. (2007). The developmental perspective

in integral counseling. Counseling and Values, 51, 180–192.

Corey, G., Corey, M., & Callanan, P. (2011). Issues and ethics in the

helping profession (8th ed.). Pacific Grove, CA: Brooks/Cole.

Council for Accreditation of Counseling and Related Educational

Programs [CACREP]. (2009). 2009 standards for accreditation.

Alexandria, VA: Author.

Endicott, L., Bock, T., & Narvaez, D. (2003). Moral reasoning, inter-

cultural development, and multicultural experiences: relations

and cognitive underpinnings. International Journal of Intercul-

tural Relations, 27, 403–419.

Hill, A. L. (2004). Ethical analysis in counseling: A case for narrative

ethics, moral visions, and virtue ethics. Counseling and Values, 48,

131–148.

Kitchener, K. S. (1984). Intuition, critical evaluation and ethical

principles: The foundation for ethical decisions in counseling

psychology. Counseling Psychologist, 12, 43–55.

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turalism summit: Challenges and pitfalls. In P. Pedersen (Ed.),

Multiculturalism as a fourth force (pp. 61–72). Philadelphia, PA:

Brunner/Mazel.

McAuliffe, G., & Eriksen, K. (Eds.). (2011). Handbook of counselor

preparation: Constructivist, developmental, and experiential

approaches. Thousand Oaks, CA: SAGE.

Watt, S. K., Robinson, T.L., & Lupton-Smith, H. (2002). Build-

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94–100.

Warren, J., Zavaschi, G., Covello, C., & Zakaria, N. S. (2012). The use

of bookmarks in teaching counseling ethics. Journal of Creativity

in Mental Health, 7, 187–201.

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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.
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
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
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: drlizgoren@gmail.com

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Psychoanalytic Psychology © 2017 American Psychological Association
2017, Vol. 34, No. 2,

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mailto:drlizgoren@gmail.com

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?)

“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 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.

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 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,

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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
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 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
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;
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
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

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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
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
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
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
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,
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.

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218 GOREN

Green (1995) attributed the de-sexualization of psychoanalysis
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 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.

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-
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
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
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
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te
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by
th
e
A
m
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P
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al
A
ss
oc
ia
ti
on
or
on
e
of
it
s
al
li
ed
pu
bl
is
he
rs
.
T
hi
s
ar
ti
cl
e
is
in
te
nd
ed
so
le
ly
fo
r
th
e
pe
rs
on
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us
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of
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in
di
vi
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us
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an
d
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to
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di
ss
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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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dx.doi.org/10.1080/07351699109533843

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an
P
sy
ch
ol
og
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al
A
ss
oc
ia
ti
on
or
on
e
of
it
s
al
li
ed
pu
bl
is
he
rs
.
T
hi
s
ar
ti
cl
e
is
in
te
nd
ed
so
le
ly
fo
r
th
e
pe
rs
on
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us
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of
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in
di
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us
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d
is
no
t
to
be
di
ss
em
in
at
ed
br
oa
dl
y.

220 GOREN

http://www.theonion.com/blogpost/boy-ive-really-put-you-in-a-tough-spot-havent-i-34949

http://www.theonion.com/blogpost/boy-ive-really-put-you-in-a-tough-spot-havent-i-34949

http://www.aasect.org/code-ethics

http://www.apsa.org/code-of-ethics

http://www.apsa.org/code-of-ethics

http://www.apa.org/ethics/code/

http://www.apa.org/ethics/code/

http://dx.doi.org/10.1080/10481881009348534

http://dx.doi.org/10.1080/10481881009348534

http://dx.doi.org/10.1080/00107530.2008.10747146

http://dx.doi.org/10.1080/10481880903558981

http://dx.doi.org/10.1521/jaap.29.3.403.17298

http://dx.doi.org/10.1521/jaap.29.3.403.17298

http://CBSnews.com

http://dx.doi.org/10.1080/10481889409539011

http://dx.doi.org/10.1080/10481885.2013.772479

http://dx.doi.org/10.1080/10481885.2013.772479

http://dx.doi.org/10.1080/00107530.2011.10746441

http://dx.doi.org/10.1080/00107530.2011.10746441

http://dx.doi.org/10.1516/0020757001600426

http://dx.doi.org/10.1516/0020757001600426

http://dx.doi.org/10.1080/10481885.2013.772481

http://dx.doi.org/10.1080/10481885.2013.772481

http://dx.doi.org/10.1177/0003065113501868

http://dx.doi.org/10.1177/0003065113501868

http://dx.doi.org/10.1080/01062301.2002.10592737

http://dx.doi.org/10.1177/00030651040520011101

http://dx.doi.org/10.1177/00030651040520011101

http://www.socialworkers.org/pubs/code/default.asp

http://dx.doi.org/10.1111/bjp.12017

http://dx.doi.org/10.1080/10481885.2013.772484

http://dx.doi.org/10.1080/10481881309348751

http://dx.doi.org/10.1080/07351699109533843

http://dx.doi.org/10.1080/07351699109533843

• A Call for More Talk and Less Abuse in the Consulting Room: One Psychoanalyst–Sex Therapi …

Psychoanalysis and Sexual Abuse: A Society and Profession in Turmoil
How Analytic Culture and Practice May Contribute to SBV Risk
Clinical Training on Sex in the Consulting Room
Recommendations and Conclusions
References