2.10 The failure of CAM therapeutic relationships: sexual abuse and exploitation
Another issue that can cause a therapeutic relationship to break down is the failure to maintain appropriate personal or professional boundaries, to the extent that it constitutes serious abuse. A broad spectrum of activities can be called abuse. The term ‘abuse’ originates from the Latin meaning ‘a departure from the purpose (use)’ (Rutter, 1990, p. 41). Given this meaning, clearly some of the boundary issues mentioned above are on the fringes of the category of abuse within CAM. Much of the literature on abuse in one-to-one healing encounters is from counselling and psychotherapy and focuses on the issue of sexual abuse and exploitation within the therapeutic relationship (for example, Pope and Vetter, 1991; Jehu, 1994).
Perhaps the most easily identifiable abuse within CAM relationships is where a practitioner makes sexual moves towards a user or engages in a sexual relationship. Such behaviour constitutes a gross breach of trust. Such boundary violations are invariably counter-therapeutic, whatever the practitioner and the user may feel about it. As with all boundary violations, sexual exploitation is no more likely in CAM therapeutic relationships than in other healing encounters. However, factors which might increase the likelihood of abuse in CAM include working from home, or in other informal settings (including the user's home), lack of knowledge about what the therapy is supposed to involve, and lack of formal regulation (Stone, 2002).
Sometimes a breach of boundaries starts when a patient or user attempts to change the nature of the relationship. Oerton's research (2004) on therapeutic massage indicates that it is very common for practitioners (often, but not always, female) to have problems with clients (often, but not always, male) misinterpreting massage as sexual. Massage practitioners have the added problem of being incorrectly associated with sexual massage services. Oerton found that practitioners often sanitise the encounter to minimise the possibility of misinterpretation by wearing white tunics or robes (mimicking the dress of medical personnel); adopting a professional attitude to the massage encounter; and demonstrating boundaries by leaving the room while the patient or user is undressing and dressing. Working in a group practice of CAM practitioners can also help deter people or their therapists from trying to breach acceptable boundaries.
The processes of transference and counter-transference make it natural and normal for attraction and desire to arise for both user and practitioner throughout the therapeutic relationship. Transference is the way in which a user's feelings and actions towards their therapist are influenced by early childhood experiences, especially relationships with parents. Therapists, in turn, exhibit counter-transference: their own unconscious fantasies and wishes about their patients. Practitioners need to be aware of these forces and use them constructively in the professional relationship (Stone, 2002). The onus is always on the practitioner to manage and maintain appropriate boundaries, however the user behaves. Mitchell and Cormack (1998, p. 102) note that users are most likely to be abused sexually: where the practitioner's general behaviour is anti-social or domineering; if the practitioner works alone; if there are drug and/or alcohol problems and/or other sources of distress in the practitioner's life; and if the practitioner can rationalise that it is acceptable to use the therapeutic relationship for intimacy. Clients who are ‘excessively dependent’ are the most likely to be sexually abused by practitioners, as are clients who feel sorry for the practitioner or who have a need to please the practitioner. People who have suffered sexual, physical or emotional abuse at other times in their lives are particularly vulnerable to an abusive dynamic in the therapeutic relationship (Mitchell and Cormack, 1998, p. 103).