Professional Sexual Misconduct in Institutions E-Book

Werner Tschan

• Herausgeber: Hogrefe Publishing
• Kategorie: Geisteswissenschaft
• Sprache: Englisch
• Veröffentlichungsjahr: 2013

Seitenzahl: 387

Beschreibung

Essential reading about a notoriously difficult problem: how abusive professionals manipulate their clients and what we as organizations and individuals can do about it Professional sexual misconduct (PSM) is a problem that is notoriously difficult to address and that can be a minefield for all concerned - for victims, for the institutions where it takes place, and also because outstanding and supposedly responsible members of society may be accused of abuse. Here, Werner Tschan, one of the world's leading experts on the prevention of PSM, outlines an up-to-date approach to PSM and other professional disruptive behaviors. He describes practical ways to prevent PSM, as well as effective treatments for victims and those accused. Using examples from real-life cases from around the world, he also discusses how PSM is a societal problem and what we can do to stop it. Recent headline cases involving a variety of organizations - medical, media, church, schools, sport, industry - show that institutions can be ideal environments for PSM and so great emphasis is placed in this volume on preventive measures that we can and must take at an institutional level. With clear, jargon-free writing, this book is essential reading for all professionals interested in preventing and dealing with PSM, as well as of interest to victims and their families as well.

Leseprobe

Professional Sexual Misconduct in Institutions

About the Author

Werner Tschan, MD, runs a private practice in psychiatry in Switzerland. He serves on the Advisory Board of AdvocateWeb (http://www.advocateweb.org). He gives lectures and workshops worldwide and has published numerous articles on the subject of professional sexual misconduct. Dr. Tschan undertook his postgraduate training at the University of Mainz, Germany, on the treatment of sexual offenders. This, together with his master’s degree in Applied Ethics at Zurich University, gives him the professional background to answer ethically challenging questions. He has dedicated much of his professional career to the prevention of interpersonal violence and received recognition for this in being given the AdvocateWeb award Boundary Angel in “recognition of worldwide dedication to victims of sexual exploitation” in 2006.

Dr. Tschan provides solutions for professionals and institutions in how to deal with professional sexual misconduct (PSM) and assists regulating authorities in improving legal proceedings and interventions. In close cooperation with colleagues, he has developed a modular-based boundary training program for the rehabilitation of professionals after PSM. Werner Tschan has served as chair of several task forces on the behalf of state or national medical associations to study the problem of PSM among health care professionals. He was a member of the German government Round Table Against Sexual Abuse. He is also involved in the postgraduate training of professionals from various backgrounds (physicians, mental health professionals, the clergy, forensic professionals, human resource management, and lawyers) as well as performing assessments of impaired professionals and being involved in their treatment and rehabilitation.

Professional Sexual Misconduct in Institutions

Causes and Consequences, Prevention and Intervention

Werner Tschan

Library of Congress Cataloging in Publication is available via the Library of Congress Marc Database under the LC Control Number 2013946867

National Library of Canada Cataloguing in Publication Data Tschan, Werner, 1953-, author           Professional sexual misconduct in institutions : causes and consequences, prevention and intervention / Werner Tschan.

Includes bibliographical references and index. Issued in print and electronic formats. ISBN 978-0-88937-444-7 (pbk.).--ISBN 978-1-61676-444-9 (pdf).-- ISBN 978-1-61334-444-6 (epub)

          1. Sex crimes. 2. Sexual harassment. 3. Professional employees--Sexual behavior. 4. Sexual abuse victims--Rehabilitation. 5. Sex crimes--Prevention. 6. Sexual harassment--Prevention. I. Title.

HF5549.5.S45T73 2013

658.3’145

C2013-905433-2 C2013-905434-0

© 2014 by Hogrefe Publishinghttp://www.hogrefe.com

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Format: EPUB

ISBN 978-1-61334-444-6

Foreword

“Everyday you must walk the fine line between courage and caution.” B.K.S. Iyengar

A life time of work went into this book. Dr. Werner Tschan has made sense of his own childhood trauma that was compounded by poor treatment by physicians and therapists. His lived experience as a victim and as a professional has given him deep sensitivity to the myriad of difficulties experienced by victims and perpetrators.

Dr. Tschan addresses the question of how to diagnose survivors who are unaware that what they experienced was abuse. It is a difficult feat to help a victim of PSM, name the abuse that so closely matches incest. Both abuses are confusing as the perpetrators are meant to be trusted and to offer security. Healing from both requires that someone safe travels with the victim on the healing journey. Dr. Tschan offers direction on how to do this effectively.

Along the way Dr. Tschan has found that learning about the perpetrator may help ensure that further abuses are not committed by the offender. The possibility of rehabilitation of perpetrators is questionable. It is honorable to work towards the safety of victims by attempting to have the perpetrator acknowledge their offense and never offend again.

Professional societies need to look at how their systems produce and protect perpetrators. Dr. Tschan offers suggestions for stopping abuse by professionals by urging policies that invite disclosure. It’s only by having the will to act on these invitations that abuse by professionals will be stopped.

Dr. Tschan became a psychiatrist in 1989. He entered into private practice and when confronted with a patient who shared that she had been abused by a professional he asked for consultation. Many told him that it was only a fantasy and should be handled from that perspective. He chose to believe the patient’s story and from there his need to speak out strengthened.

Dr. Tschan was appointed to the State Association of Psychiatrists of Basel, Switzerland and charged with the task of learning what to do with offending psychiatrists. On a trip to the US in 1998 he met Gary Schoener, a licensed psychologist and expert on the subject, who urged him to speak out and he’s never looked back.

I met Dr. Tschan on the internet. Advocateweb.org was the largest, most complete, and well respected web-site concerning abuse by professionals. The founder of the list, Kevin Gourley, realized that there were many people who were advocating for victims. Kevin started a closed forum for these advocates to get and offer support to each other. Werner and Gary joined with about 10 of us who were assisting victims. It is a testimony that the line between peer advocacy and professional advocacy could be complementary. We have all helped each other.

Now with the support of his family he has written this book. We’ve needed a fresh look at how abuse by professionals affects us all. We need a book that has been researched enough to be accepted by professional groups as well as straightforward enough so that the traumatized client can read and make sense of their experience. One of the most harmful aspects of abuse by professionals is that the victim can no longer trust health care providers. This book will help bridge the gap until that trust can be regained.

It’s been my pleasure to get support from and give support to Dr. Tschan. I applaud his faithfulness to the needs of all touched by this terrible crime.

Ann Van Regan, Ottawa TELL (Therapy Exploitation Link Line)

Table of Contents

Foreword

Dedication

Preface

Survivor’s Voice: A True Story of an Elderly Man Reaching Out for Help

1    

Introduction

1.1.    

Historical Background

1.2    

Children’s Lies – The Backlash After 1900

1.3    

The End of “Hystories”

1.4    

Developments in Europe

1.5    

New Penal Codes

1.6    

Public Awareness

1.7    

Awareness Psychology

2    

How to Understand Survivors’ Reactions

2.1    

Attachment Theory

2.2    

Trauma and Its Consequences

2.3    

Delayed Onset of Symptoms

2.4    

Overcoming Trauma

2.5    

Society’s Answer to Trauma

3    

What Is PSM and How Does it Happen

3.1    

What Is PSM?

3.2    

What Is the Magnitude of PSM?

3.3    

The Spectrum of Offense

3.4    

Who Becomes a Victim of PSM?

3.5    

What Are the Consequences of PSM?

3.6    

How Can PSM Be Discovered?

3.7    

False Accusations of PSM

3.8    

What Helps Victims of PSM?

3.9    

Liability Questions

3.10    

Who Becomes an Offender Professional?

3.11    

Sexuality and PSM

3.12    

Punishment or Treatment?

4    

PSM in Various Disciplines

4.1    

Health Care Professionals

4.2    

Psychotherapy and Counseling

4.3    

Social Work

4.4    

Care Homes

4.5    

Religion

4.6    

Education

4.7    

Sports and Leisure Time Activities

4.8    

Justice System

4.9    

Military

5    

The Overlap with Workplace Violence

5.1    

The Culture of Organizations as a Management Task

5.2    

Sexual Harassment

5.3    

Bullying

5.4    

Stalking

5.5    

Physical Violence

5.6    

The Decision-Making Process

5.7    

Problem-Solving Attempts

5.8    

Prevention of Workplace Violence

6    

The Impact of PSM on Survivors, Institutions, and Professionals

6.1    

From Victim to Survivor

6.2    

Consequences for Offender Professionals

6.3    

Consequences for the Institution

6.4    

Consequences for Society

7    

Treatment of Survivors

7.1    

Realizing

7.2    

Finding Help

7.3    

Processing

7.4    

Integration

7.5    

Overcoming

7.6    

Healing

7.7    

From Victim to Offender

8    

Why Do Professionals Commit Sexual Offenses?

8.1    

The First Meeting

8.2    

Treatment Procedure

8.3    

The Path to PSM

8.4    

Offender Strategies

8.5    

Homework During the Treatment Program

8.6    

Evaluation and Termination of Program

8.7    

Prognosis

9    

Prevention of PSM in Institutions

9.1    

Effective Complaint Mechanisms

9.2    

False Accusations

9.3    

The Decision-Making Process

9.4    

An Integrated Approach

10    

Boundary Training

10.1    

A New Paradigm: Rehabilitation After PSM

10.2    

The 24 Modules

10.3    

Who Should Undergo Boundary Training?

10.4    

Boundary Training in Professional Formation and Further Development

10.5    

We Don’t Need to Re-Invent the Wheel

11    

Assessment and Rehabilitation of Affected Professionals

11.1    

Assessment

11.2    

Rehabilitation Program

11.3    

Critical Questions

11.4    

Case Consultation and Supervision

11.5    

Economic Consequences

11.6    

Risk Management

12    

Prevention Overview

12.1    

Victim Counseling Services and Other Requirements

12.2    

Curricular Integration

12.3    

Paradigm Shift in Justice

12.4    

The Three Pillar Model for Effective Prevention

References

Index

Dedication

This book is dedicated to the survivors of sexual abuse by professionals in the hope that it will help to give survivors a voice and to overcome the silence covering the subject. The book should also be helpful for associated survivors to provide them with a better understanding of what their loved ones have been through. It is crucial that professionals understand the concept of boundaries and the consequences of their transgression. Only those in power are able to stop offender professionals.

Preface

Helping PSM survivors is the main aim of this book; however, stopping offender professionals is no less important. Institutions (professional settings) must be considered as high risk places for sexual offenses due to the many existing opportunities and also due to the vulnerability and dependency of the clients on their professionals. Sexual offenses by professionals take place in residential care, in medical treatment, and can be committed by teachers, sport coaches, clergy, police officers, babysitters, to name just a few. Approximately 25% of all sexual offenses are committed by professionals in their professional capacity. Often (potential) victims have no choice which professionals they will see (e.g., people in care homes, schools, etc.). This places the responsibility of carefully selecting and monitoring professionals in their work into the hands of regulating authorities.

When Henry Ellenberger in his writings on the renown Pierre Janet emphasizes that “no researcher … ever works alone” (Ellenberger, 1970, p. 481), the same is true for me in my own work. My writing is based on the tremendous work that others have done before me, and it is also based on the first-hand experiences of survivors. I began this work when treating victims in the aftermath of PSM, and through this I realized the full extent of the taboo covering this problem. Whilst undertaking this work, I also realized the urgent need for the development of treatment and rehabilitation programs for offender professionals. This should not be misinterpreted that offender problems come first, on the contrary. We should avoid these kinds of polarizations as it has become clear that victim support and stopping offender professionals must go hand in hand. It is common knowledge today that offender treatment is the most effective strategy to prevent further sexual crimes. The results and insights gained from the treatment of offender professionals influences my practice – insight into their modus operandi was immensely helpful in improving preventive strategies.

Despite the fact that my main professional interest is still the treatment of affected survivors, I have been questioned as to why I also focus on the rehabilitation of offenders. On the other hand, I have also been questioned by professionals as to why I help survivors. My answer was not really heard: I am a physician and therefore my moral, legal, and professional duty is to help, to cure, and to heal. In my role as a physician I do not take sides, although I make it very clear to offender professionals that their behavior is unacceptable. But, at the same time, I express my respect for them that they have decided to seek help and that they intend to overcome their difficulties. The work of others (e.g., Danesh, personal communication, January 1997) has helped me to conceptualize what a healing journey for society as a whole would look like when confronted with such atrocities committed by highly respected and trusted members of society. Reconciliation and peace building are indispensible in overcoming the traumatic effect of PSM.

I would like to thank personally all my friends and colleagues who have read several drafts of the manuscript and have provided many stimulating additions. I am indebted to native English speaking Clare Kenny who has helped to improve the style of the book considerably, making it reader-friendly. I acknowledge with a special thank you the Foreword provided by Ann Van Regan and the Survivor’s Voice written by Jimmy Haran. We have collaborated for many years and have shared concerns and ideas. I also appreciate the valuable contribution of my wife, Melanie. She and my family have supported and encouraged me a great deal and have provided me with a unique space for creativity, which has enabled this book project.

Three salient aspects of this book should be noted by the reader, as outlined in the following paragraphs.

Survivors’ perspective. I have aimed to write the book from a survivors’ perspective. Survivors have become experts through their devastating experiences. In my book I address them as often survivors instead of as victims; even “heros” when they have the courage to disclose their stories and break the silence. The request for an independent and neutral observer in the face of sexual exploitation is both morally and scientifically nonsense. Even from a legal standpoint the neutral position is misleading: many professionals are obliged to report incidents which therefore force them to make decisions which remove their neutrality. Each person’s individual perspective determines their point of view. Even hard sciences like physics have recognized that the observer always influences the process s/he is observing. All intervention strategies towards preventing sexual violence can only be designed from a survivors’ perspective to be effective. The goal is to protect vulnerable people. All endeavors, whether they are therapeutic, legal, or administrative, must be evaluated in relationship to whether they provide the immediate and effective protection of any potential victims and whether they lead to adequate interventions for the offenders, which would then help to avoid further offenses. Only those in a position of power are able to stop offenders.

The reader can put this book aside whenever they decide; survivors, on the other hand, cannot put aside their pain and suffering simply because they feel they can no longer carry their burden. They have no choice and they will often suffer from what has been done to them for the rest of their lives. These effects are best described as polyvictimization, because it is not “only” the sexualized violence they have experienced, but also the breakdown of trust and the emotional turmoil they went through. They are often not believed or respected, and their pain and suffering are not acknowledged, all of which have been inflicted on them by state licensed professionals, by clergy, etc. This book puts the focus on what many people tend to ignore: Sexualized violence takes place in front of our noses and we do not perceive it. This book aims to awaken the reader without being polemic. Most case examples in this book are from the media; in most cases from daily newspapers. These examples will hopefully help the reader to understand the survivor’s perspective and will also help to challenge how such cases are handled, which is often unacceptable.

Evidence-based approach. The subject of PSM is situated within applied ethics, jurisprudence, medicine, and anthropology. None of the involved disciplines is able to solve the problem alone. There is a need for interdisciplinary collaboration, which requires new scientific approaches beside traditional models. Attempts have been made to instrumentalize PSM and there are accompanying controversies. The author, therefore, relies on evidence-based facts. This scientific approach leads to conclusions which create a paradigm shift. Instead of coming to decisions based on misleading assumptions or, even worse, using the put-the-head-in-the-sand strategy, this book presents practical approaches. Nevertheless, this approach must be evaluated as to whether it really contributes to solving the problem. The author believes that this subject must be discussed scientifically. My colleagues Ferring and Willems from the University of Luxenbourg are among the first academics who have ignited the discourse by focusing on the conditions which lead to the abuse of power in professional setting (Ferring & Willems, 2011). This approach culminated in the formulation of a victim-offender-institution dynamic as a framework for understanding PSM.

Transdisciplinary impact. PSM affects victims and their relatives first of all; they are striving for answers. However, the public must also be informed, not only the professional community. There must be a clear understanding of the underlying mechanism of sexual boundary violation and its prevention. The very same answer is required of all involved disciplines. PSM has nothing to do with transference love; it violates professional standards and constitutes a clear criminal act. There is a need for free-of-charge counseling services operating within an open door policy – only then will survivors come forward and disclose what has been done to them. This will only happen when they can be sure that they are protected and that effective interventions are undertaken in order to prevent further sexual offenses by professionals. Recent extensions of the Human Rights Declaration (1948), such as the Convention on the Rights of Children (1989), clearly and unquestionably claim that state parties implement all necessary steps to protect citizens from all forms of violence through primary, secondary, and tertiary prevention strategies. PSM as well as sexual violence in general is a global issue (Tschan, Kumagai, & Miyaji, 2008), making it the greatest “pandemic” humanity has been confronted with. The book aims to provides an orientation on boundary issues which is not only helpful for the involved professions but for society as a whole.

Survivor’s Voice: A True Story of an Elderly Man Reaching Out for Help

My career as a Civil Engineer finished abruptly as the result of a fall a couple of years ago. During my recovery I decided to use some of my free-time training to be a counselor. I believed that motivating staff on a construction site and dealing with their everyday concerns to get the job done was not too far removed from facilitating my fellow mortals to achieve wholeness.

After some years of training, I became a founding member of a counseling group in Galway that was set up by the Galway Rape Crisis Centre to counsel men who had been sexually abused some time in their lives, but usually as boys. Though committed to the group and its work, I wondered if I should have re-trained in my former profession and spent the rest of my work life in an office.

One day in November, only a few weeks after opening the service, the helpline phone rang. The hesitant voice of an elderly man, who I will call Martin, enquired: “Are you the people who talk to men like me?” I introduced myself to him, explained the nature of our work and that it was a free service and was independent. A few seconds passed and I knew that he was having difficulty finding the next words. Martin told me he was 78 years of age and that his wife had died two weeks ago at their remote farmhouse in the west of Ireland. Their married life was miserable and right to the very end his wife was angry that he had treated her and their children so badly. He went on to say that soon after their marriage she discovered that he was an alcoholic, subject to huge mood swings, and was verbally abusive. His drinking had caused the family to be impoverished and some of his children still refused to meet him. “If only I had been brave enough to tell her of the hell I have lived through in my head all these years,” he said. “I have protected her and the rest of the family from knowing that the priest sexually abused me when I was an altar boy after Mass. He abused me in the sacristy from the age of 7 to 12 most mornings before I went to school and I couldn’t tell anybody.” Martin sobbed like a child before telling me that he hated himself as much as the perpetrator. He went on to say that in the days and nights since his wife’s death he has asked her forgiveness for the unhappiness he had caused her and the other family members, knowing that she was in a happier place and would now understand. Three or four times he repeated the words “If only I told her, she would have loved me.” Martin then very calmly said that he wasn’t interested in coming into the Centre for counseling as it was too late. When I asked him if he had ever spoken to anyone else about the abuse he said: “Not a soul Jimmy, not a soul. I just wanted to tell one person and I’ve done that.” He thanked me for listening, adding that it was a great burden off his chest.

Two or three minutes later the helpline rang again. It was Martin. He said that he had been on the point of telling his wife about the abuse several times but there was never the right time, “children and life got in the way.” I asked him if he felt he could now tell those same children what he would have liked to have told his wife. I was thrilled with his answer: “Well I just might.” Then Martin said: “It was good to talk to you Jimmy. When it’s my turn to go I can go in peace. Goodbye.”

My concerns that I was not in the right line of work evaporated after speaking with that remorseful old man. I have not heard from him since but I choose to believe he has been leading a happier and fulfilled life since our conversation one morning a couple of years ago.

Jimmy Haran MASC Male Abuse Survivors Center, Galway, Ireland

1

Introduction

In order to end darkness you only have to switch on the light for darkness does not shine.Confession of a Seeker, Paul Coelho (2001)

The aim of this book is to provide essential knowledge on professional sexual misconduct (PSM) and how to stop offender professionals. The term PSM is used for all forms of sexual boundary violation when committed in a professional role. The information provided here will be of great help to professionals, survivors of PSM, and associated survivors. It is also helpful to students from various disciplines in providing a better understanding of the nature of professional boundaries, which define the duties and limits of professionals. The professional is in a fiduciary position towards the client, and the professional-client relationship is characterized by a significant power difference based on the professional’s knowledge and role. The concept of boundary has evolved over the years and it is now founded on both legal requirements and professional standards. Only professionals have a code of conduct (professional guidelines), and, therefore, boundaries constitute a unilateral duty of professionals and remain something which can never be delegated to the client. This is analogous to physicians who must provide sterile conditions when performing operations. The boundary concept, although seemingly clear, leads to ongoing controversies. The author provides evidence-based data on the subject and discusses various ways to support survivors and how to handle accused professionals, thereby providing essential orientation in this complex subject.

This book provides answers to questions such as: What are professionals’ boundaries? What constitutes PSM? Why do professionals transgress or violate these boundaries? What are the resulting effects of boundary violations? What do we know about the modus operandi of offender professionals? What helps affected victims to overcome their experience? What should be done with accused professionals? How can offender professionals be stopped? What is of preventive effect, if at all?

Offender strategies have to be identified to help us to understand how offenders manipulate their victims, how they overcome victim’s resistance, how they silence their victims, and how they also manipulate investigative staff, judges, and professional colleagues.

PSM occurs in many disciplines ranging from within the health care system, to sports, education and religious counseling. Due to the large number of existing opportunities, professional settings must be considered as high risk places for sexual offenses. This is comparable to intrafamilial offenses: There is a structural power difference between clients and professionals that is similar to child sexual offenses. The terms “victim” or “survivor” of PSM are used interchangeably in this book. Both terms address the vulnerability of the person in care, i.e., the position of the client, student, parishioner, or patient towards the professional when it comes to sexual boundary violation.

Treating victims of PSM challenges traditional therapeutic approaches. The dialectic behavioral treatment approach helps to overcome these hurdles. Between the declared principles and commitments of institutions and the real handling of PSM cases there is often a double standard between what professionals are supposed to do and what they actually do. This book is not an easy read. The reader is confronted with many atrocities from the everyday reality of survivors. Contrary to survivors the reader is able to put the book aside whenever it gets too much.

Despite these difficulties the reader is invited to follow the text in the given order, which is didactically structured. Doing this without prejudgment will help to bring about new understanding. The examples used in the book are taken from the media and from the author’s first-hand experiences. The case examples have been changed in order to protect identities. The book’s aim is to be reader-friendly so that anybody interested in the subject is able to follow.

When discussing PSM it is important to realize that there are many myths blurring correct awareness of the subject. One of the first among them: “Oh yeah, we know about all these false allegations,” often said by otherwise well-informed professionals. “Well trained professionals would never do such a thing,” which unfortunately is not the case, as we know from many examples of top-ranking professionals who have been sentenced for having committed PSM. “If she really had resisted, there would be no such thing,” then you should think about drug facilitated sexual assaults, when offender professionals use anesthetics, sedatives, or simply alcohol to knock out victims. “If she hadn’t provoked him, this would never have happened to her,” or “No wonder, when she dresses like that.” Many myths exist which all blame survivors of being either responsible for the offense or having wanted a sexual affair with the professional. The evidence-based facts contradict these myths entirely. You can never be just a little bit of an offender as too a woman cannot be slightly pregnant, as these are not black and white matters. Either someone is or is not – there is nothing in between. “He was only fondling a little bit,” “It was not even penetration,” “It happened just once,” “Well, it was nothing serious, we all knew that he behaved this way all the time,” “She makes a mountain out of a molehill.” The question is always whether this behavior is in accordance with professional standards or not. What makes it even more complicated is the fact that the correct behavior is always context dependent – giving someone a hug may be appropriate under certain conditions, but it may also be completely unprofessional and inappropriate. One should always ask oneself the question: “Is this something one would expect a reasonable professional to do under the given circumstances?”

The book intends to provide answers to these questions. The historical background of the subject is set out in the introduction. Evidence-based data on PSM is available right back to the time of the Enlightenment (Clark, 1987; Kerchner, 2000). Some more anecdotal texts go back even further (Deacy & Pierce, 2002), such as when the physician Archibald Cleland was fired from the Bath General Hospital in 1743 after three of his female patients had come forward with accusations of sexual offenses (Fissel, 1993). In 1803, Thomas Percival coined the term “medical ethics” when he published his book on Medical Ethics or a Code of Institutes and Precepts, Adapted to the Professional Conduct of Physicians and Surgeons (Jonsen, 2000). Through this book he opened up the discussion about professional behavior, anticipating what has later become known as disruptive behavior. Also of great importance to this subject are ancient Greek texts, namely the work of Hippocrates, who formulated a code of conduct for physicians. His writings laid down the foundations for the ethical awareness of the importance of the physician-patient relationship, a discussion which was further influenced by the involvement of physicians in the Nazi terror regime (Kater, 1989) and the involvement of physicians in torture and human experiments. How is it possible that physicians who had sworn the Hippocratic Oath could lose their moral compass? This same question can be asked in the case of PSM. Medical ethics has played a central role in the codification of the professional-client relationship, and has widely influenced other disciplines in their attempts at implementing professional codes, as well as in the formulation of laws. However, significant inconsistencies exist, insofar as the majority of criminal codes only regulate health care professionals, whereas other disciplines such as teachers, sport coaches, clerics, and lawyers often lack any regulation of PSM.

In Europe, the implementation of effective laws against PSM is around 20–25 years behind that in North America, Australia, and New Zealand Contrary to the situation in these countries, mandatory reporting of PSM is rather an exception to the rule, and legal protection for those who report such incidents is almost nonexistent. The consequences for accused or sentenced professionals are minimal, if at all. The handling of such cases does not follow established protocols, and there are no rehabilitation concepts in effect. The situation in Asia is comparable to that in Europe. On the other hand, North America, Australia, and New Zealand have good standards, and protocols are in place to handle PSM. Within Europe, Germany took the pioneering role when it implemented a new penal code, 174c, in 1998, and in its subsequent revision in 2003. In a worldwide comparison, this is now one of the most advanced criminal articles banning sexual boundary violations in the health care sector (Tschan, 2005). The legal comments on this law clearly stipulate that the responsibility of maintaining healthy boundaries always and exclusively lies with the professional, even if the patient initiates intimate contact (Joecks, Miebach, & von Heintschel-Heinegg, 2005). The Round Table on the prevention of sexualized violence initiated by the German Government after numerous cases of sexualized violence came to light (among them the UNESCO awarded Odenwald School) led to significant consequences:

•   A 50 million Euro research grant

•   A 100 million Euro fund for survivor support

•   Guidelines on the curricular training of health care professionals and teachers

Effective intervention will fail without the understanding of the modus operandi of offenders and of the dynamic process between victim, offender, and institution. According to most criminal justice systems, the burden of proof lies with the victim, who as a result of the traumatic nature of PSM is already in a weak position. Furthermore, victims are often retraumatized through legal procedures, a phenomenon which is described as secondary traumatization. Transferring the burden of proof (analogous with civil law) is unknown in cases of PSM and would challenge legal procedures fundamentally. It is not surprising then that survivors of PSM hesitate to come forward with allegations. If the court does not accept their claims of traumatization they also carry the burden of financial risk. Similar to the doctrine of the assumption of innocence there is an urgent need to have a corresponding doctrine for survivors; to believe in the victims of sexual offenses requires a proactive human process. The offender friendly approach of current judicial systems needs a fundamental paradigm shift.

The first chapter sets out the definition of PSM and provides an overview of the topic, starting with the various myths related to PSM. The historical background of the subject is outlined and the reader will learn how the boundary concept has developed over the years. Backlashes are described in order to understand current controversies relating to the subject. As most victims are silenced, the understanding of the problem must be based on evidence-based facts and not on misleading assumptions. The book outlines that the process of listening to victims must be a proactive process, and that victims must see the consequences of their reporting. Only when their disclosures are recognized as an important contribution in improving the level of professionalism within the institution will they come forward. Because of the controversies accompanying the subject, a few words on awareness psychology conclude this introduction.

The second chapter provides an overview on psychotraumatology and attachment theory. In all cases, PSM is a relational offense due to the fact that the professional holds the position of a specific attachment figure. The sexual offenses take place in secret, and most victims are silenced either by the professionals themselves or by the institution behind them. Society contributes in maintaining this silence by ignoring the subject. Survivors also keep silent for various personal reasons. When offered a safe place, victims start talking about their devastating experiences; however, listening to these stories is not an easy task. It confronts the bystander with atrocities which are hard to believe. Professionals supporting affected victims often come under fierce attacks by the same forces that want to keep the subject under the carpet. Psychotraumatology and attachment theory are crucial for understanding the victims’ reactions. For the first time in its history, psychiatry is aiming to provide a specific diagnostic category for victims of all kinds of sexual violence: The newest edition of the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5) explicitly includes “sexual violation” as a core trauma related to PTSD (American Psychiatric Association, 2013).

This chapter is essential reading for professionals on how to manage victims in the aftermath. Victims often blame themselves for being responsible; shame is, therefore, another important factor in their silence. Based on case examples, intervention techniques are described. One of the major hurdles to overcome is the simple fact that PSM took place in a professional setting – How can these victims be sure that the same thing will not happen a second time? Professionals need to address this issue proactively in order to provide a safe place for treatment.

The third chapter outlines PSM in various professional settings and describes offender strategies, bringing together evidence-based facts on the subject. Why are certain professionals committing sexual offenses and others not? The human factor is essential for understanding boundary violations. The other factors are related more to the institutions’ and society’s silence, which often enable the offense to take place. Based on sexually inappropriate fantasies, such as having sex with a client, the professional starts to target potential victims and initiates the grooming process. The process which finally leads to the sexual offense takes place step by step. The professional setting offers an ideal place in which to test the waters – Nothing serious has happened so far, but due to the targeting and planning process the sexual arousal increases, and, after overcoming the victim’s resistance, the sexual offense takes place. Case examples illustrate the “path to PSM.” The gender relation between professional and client is described and then the similarities and differences to heterosexual offenses are outlined. What we currently know about the magnitude of offenses in various disciplines and the accuracy of existing data are discussed. Various other forms of boundary violations are described as well as sexual offenses. Who becomes a victim of PSM is then discussed, including the consequences for them. The subject of false accusations is addressed, and how to react in such situations is described. Finally, the relationship between sexuality, the search for intimacy, and offenses by professionals is outlined. This chapter is essential for the implementation of preventive strategies.

In Chapter 4, the various disciplines where PSM occurs are described in detail. We currently have a considerable amount of data on sexual offenses in various professional backgrounds. Most studies are based on anonymous questionnaire-based data collection, where the reliability is questionable. However, this data, at the very least, gives us an idea of the magnitude. Some consumer reports, based on population studies, however, provide accurate data on incidence. Starting with the health care sector, the professional areas of religion, education, sports, leisure time, the justice system, and the military are also all explored. The reader learns the various forms of PSM in each of the professional backgrounds and how each affects client-professional relationships. It is important to note that the outlines of this chapter rely on evidence-based facts collected over the last three decades. The data collected from the various disciplines clearly emphasize the need to take action and to ignore the problem no longer.

To provide a comprehensive understanding of PSM in institutional settings, it is crucial to broaden the view and to discuss both interpersonal violence and workplace violence. This is described in Chapter 5. PSM is embedded in the power balance within society. This chapter outlines how society protects its citizens from violence and where society fails – the latter is described as structural violence. Sexual harassment and workplace violence are also described, i.e., when professionals themselves become victims of sexual offenses. Preventive strategies include the training of professionals in this area, creating guidelines at the workplace, and implementing reporting facilities for all kinds of sexually inappropriate behavior and other forms of violence, such as physical attacks, stalking, threats, etc. The impact of sexually inappropriate behavior outside the workplace is discussed in this chapter, when for example a teacher is accused of looking at child pornography and his or her professional capacity is then questioned. This chapter lays down the basis for an effective institutional risk management.

In Chapter 6, the effects of PSM are outlined in three different areas: the impact on survivors and their relatives; the impact on offender professionals, and the impact on institutions. For survivors, the outcome is described by the psychological, medical, social, financial and spiritual consequences, all of them interlinked with each other and undermining the person’s health conditions significantly. Professionals tend to underestimate the impact that PSM has on them as well as on the institution. Only when the problems land on their doorstep do the management react, which is certainly not the best strategy in dealing with this issue. This chapter broadens the view and focuses on the impact on victims. The author has consulted numerous institutions affected by this problem over the years and discusses his firsthand experiences.

Most survivors suffer from a polytraumatic effect which leads to a significant and long-lasting impairment to their health. The phobic avoidance reaction, which requires a specific intervention technique, is described in Chapter 7. The challenge for the survivor is to gain trust in the treating professional after the previous traumatic experience with a different professional. The creation of a trusting and safe therapeutic alliance is crucial for any survivor treatment. Integrating information about offender strategies into treatment interventions provides the survivor with an understanding of offense patterns and helps to overcome self-blame and guilt. The impact of complaint procedures both on the therapeutic process and on the survivor’s health condition is also reflected upon. The treatment of survivors confronts therapists with various pitfalls; instead of blaming victims for overreacting, therapeutic professionals should consider survivors’ reactions as an adaptation to devastating life experiences. The secondary traumatization on therapists through listening to these atrocities must be considered as an inherent risk in the profession. Possible strategies against burnout and secondary traumatization are outlined and discussed.

Chapter 8 deals with the underlying causes and explains how some professionals come to commit sexual offenses in their professional role. The knowledge of their modus operandi is based on offender treatment performed over the last thirty to forty years. This has lead to the formulation of the “path to violence” concept as a description of offender strategies. When offender professionals begin to act out their sexual fantasies towards clients this leads them on a slippery slope towards offense. The grooming process describes how these offenders manipulate possible victims and also those around them. Cognitive distortions, such as considering the client-professional relationship as a romantic affair or even a love affair, enable them to commit the offense. Other professionals may have a serious impairment in their mental health condition whereas others have paraphilic problems, such as pedophile urges. This chapter is also essential for the treatment of survivors, because this understanding helps them to overcome their feelings of shame and self blame. When they begin to understand the targeting process as part of the offender strategy, they realize their own situation for the first time in full clarity – this often leads to anger and even violent reactions. But, at the same time, this helps survivors overcome their feelings of powerlessness. The treatment process must be carefully guided by professionals to avoid negative consequences for survivors.

To describe the preconditions for offender behavior, we must examine the intervention strategies of regulating authorities. What is their awareness about the problem and what kind of risk management strategy is implemented? At which level of evidence does someone in charge react? Chapter 9 deals looks at how the decision-making process is facilitated by the implementation of task forces focusing on PSM. The implementation of adequate structures is a part of any risk management strategy, taking into account that institutions are high risk places for sexual offenses. The conflict between survivor and offender is often mirrored in the institutions’ reactions – Should the institution react or is it better to brush everything under the carpet? Are the accusations true at all or is the victim exaggerating? The accused professional is often a highly regarded coworker performing well, and, last but not least, the reputation of the institution is besmirched by all of this – Why is it not better to not react? The protection of victims and whistleblowers is an important precondition for any reporting, which then leads to a fundamental paradigm shift in the culture of handling PSM. Once again, this chapter helps survivors to better understand the failure of institutions and society, which have often done little to protect them. Again this helps them to overcome their feelings of vulnerability. On the other hand, the common approach of preventive strategies to focus mainly on victims’ empowerment is questioned by this book – those in power must stop the offenders, this cannot be the duty of already weakened survivors. The responsibilities, therefore, clearly shift to the management to implement adequate intervention proceedings. Historical evidence is cited for this, such as the case of the famous medical doctor Semmelweiss, who aimed to change the handling of perinatal care by physicians in the 18th century. It was not the weakness of the upper class society women who died of childbirth; no, it was simply the lack of adequate hygienic measures. Similarly, victims of PSM should no longer be blamed for causing all the difficulties. Instead, both institutions and professional bodies in cooperation with regulating authorities must take the leadership and responsibility in preventing PSM.

In Chapter 10, the remedial boundary training is described as well as its application in the formation and continued education of professionals. The boundary training is a modular offense-focused intervention program which integrates both sexual offender treatment techniques as well as professional competence training and rehabilitation. Based on the author’s first-hand experience with the rehabilitation of offender professionals, various case examples are used to describe the approach. For survivors, it is often essential to see the commitment of offender professionals in accepting that they have a problem when they undergo a training program. For the management of PSM cases, it is of outstanding importance that the same does not happen again and that no one else will be victimized. According to survivor surveys, this is among their first goals next to receiving a clear statement by regulating bodies that this behavior was completely inappropriate and violates fundamental professional standards. Damage compensation is, of course, another requirement, whereas punishment is not seen as a top priority on survivors’ agendas. Probably the most important effect of this rehabilitation procedure is that effective offender treatment helps to better protect potential victims. The knowledge and experience based on boundary training programs is used for training professionals.

Chapter 11