Therapist sexual misconduct has its genesis in the therapeutic relationship. The mental health professions have long recognized the delicacy with which the therapist must handle the therapeutic relationship, with its power imbalance, inherent vulnerability of the patient, and transference and countertransference reactions. The prevention of sexual contact starts with the careful attention to boundary violations, which, though themselves perhaps not harmful, may escalate into sexualized behavior. Methods of preventing this behavior include the establishment of clear guidelines for practitioners and the expansion of the educational process for therapists, therapists' employers, patients, and other professionals. Last resorts lie in the legal and quasi-legal proceedings available to victims, such as civil suits for damages, criminal complaints, board of licensing complaints, and actions before professional associations. The best method of preventing sexual contact with patients involves respecting the boundaries of the professional relationship and avoidance of the slippery slope.

Litigation is always stressful for the parties involved, and certain emotional injuries from litigation itself, termed “critogenic” (law-caused) harms, can be identified to aid attorneys in recognizing them. These harms include delay, adversarialization, retraumatization, violation of boundaries, loss of privacy, and arrested healing. After discussing critogenic benefits of litigation for balance, the authors offer approaches for minimizing the impacts of the above harms on clients.

Drawing on their own consultative experience illustrated by case vignettes and with support from the professional literature, the authors discuss the perennial problematic issue of boundary violations and sexual misconduct, aiming at an audience of both experienced and novice clinicians. The authors review the difference between boundary crossings and boundary violations and stress the therapist's responsibility to maintain boundaries. Therapist risk factors for violations include the therapist's own life crises, a tendency to idealize a "special" patient or an inability to set limits, and denial about the possibility of boundary problems. Factors exacerbating patient vulnerability, such as overdependence on the therapist, seeking therapy to find an intense relationship or even "true love," and the acceptance by childhood abuse victims of an abusive therapy relationship, are discussed. Consultation and education-for students and for clinicians at all levels of experience-and effective supervision are reviewed as approaches to boundary problems.

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