Ethical Guidelines In The Treatment Of Compulsive Sexual Behavior

By Bill Herring, LCSW

(Note: this article was originally published in Sexual Addiction and Compulsivity: the Journal of Treatment & Prevention, Volume 8, No. 1, pages 13-22, 2001. It describes an efficient way for a counselor treating clients for compulsive sexual behavior to evaluate ethically challenging situations. It emphasizes the need to provide informed consent, operate in a competent and theoretically sound manner, insure confidentiality, maintain appropriate relationship boundaries, practice with adequate supervision, and maintain clarity of cultural and personal values.)

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A counselor who knows that two group therapy clients had sex debates whether to disclose the knowledge that one client is HIV positive. A 16 year old who is frequently sexual with different partners asks a counselor not to inform her parents. A man seeking treatment for a paraphilia requests an alternate diagnosis for insurance purposes.

Counselors who treat clients for compulsive sexual behavior will regularly encounter challenging ethical dilemmas that are not typically experienced by colleagues working with a general clinical population. It is vital that clinicians have a meaningful and efficient process for determining how to respond to the unique ethical situations that can arise throughout the counseling relationship. This article describes a basic set of ethical principles that are applicable to all counselors, and gives particular attention to ethical predicaments that can occur in the treatment of compulsive sexual behavior.

The determination of whether a counselor's behavior is ethical is independent of whether it is either legally acceptable or therapeutically effective. Although operating with a solid ethical basis is helpful from a risk management perspective, ethical practice involves more than simply operating within the law. For example, a counselor may legally accept a service such as car repair from a client in lieu of a fee, but the ethical basis of such behavior remains questionable. A counselor who consistently maintains rigorous ethical standards of practice demonstrates a commitment toward protecting a client's autonomy and dignity. While this will not guarantee clinical effectiveness, it does foster a proper therapeutic environment for a client to utilize a counselor's skills to their fullest potential.

The various professional codes of ethics, while providing a useful frame of reference, are not designed to cover all ethically problematic situations that arise nor serve as a substitute for a counselor's ability to independently think through dilemmas as they emerge (Coale, 1998). A set of six core concepts that are common to most professional codes of conduct can provide a counselor with a functional basis for independently evaluating ethically challenging situations. These core concepts are to provide informed consent; to operate in a competent and theoretically sound manner; to insure confidentiality; to maintain appropriate relationship boundaries; to practice with adequate supervision; and to maintain clarity of cultural and personal values (Corey, Corey and Callanan, 1998).

Informed Consent

Informed consent is perhaps the most fundamental component of ethical practice, since it empowers the client with the requisite knowledge to form meaningful opinions about the entire course and direction of counseling. Because of the stigma and shame generally associated with compulsive sexual behavior, clients tend to feel extremely vulnerable when entering treatment and are likely to perceive themselves as possessing a relative absence of power in the therapeutic relationship. Therefore, counselors may underestimate the degree of effort that is required to insure that agreement about treatment decisions is truly given from a basis of choice. Informed consent is not a one-time event but an on-going process in which the counselor and client establish and continually monitor treatment goals and strategies as well as the roles, rights and responsibilities of all parties.

The client entering treatment for compulsive sexual behavior should be told all of the modalities that a counselor typically recommends, such as group therapy, couples therapy, family therapy, expressive therapy, medication, journaling, support group attendance, and so forth. The counselor should also clearly describe the expected benefits and any potential risks of treatment, alternative treatment approaches that may be available, the anticipated duration of treatment and the criteria for terminating services. Informed consent also includes awareness of the background and theoretical orientation of the provider, the policy for resolving any disputes that may arise during the course of treatment, and all pertinent financial issues (Houston-Vega and Nuehring, 1997).

Since this is an extensive amount of information, a counselor may choose to convey it by a combination of verbal and written means

Competence

The next core ethical concept is that a counselor should only practice within the scope of his or her professional competence. Some of the most important characteristics of clinical competence are not easily quantifiable, such as mindfulness and emotional maturity. The process for determining a counselor's proficiency therefore tends to rely on a combination of external indicators such as education, experience, training, and consultation (Pope and Vasquez, 1998). A background treating other addictive or psychological disorders does not insure an ability to meet the specific needs of sexually compulsive clients. Emerging certification standards in the field of sex addiction treatment offer a much-needed objective frame of reference for assuring that a counselor has the requisite competence to provide quality services for this specialized area of counseling.

An important component of competent practice is that counselors should operate in a manner that is consistent with an established theoretical base that clearly articulates the rationale for acting in a particular way. Counselors who are unable to adequately describe the theoretical framework which guides their clinical decisions are likely to respond to difficult situations by relying on a combination of intuition and habit. Such behavior is ethically insufficient even if the results are clinically effective (Corey, Corey and Callanan, 1998). Counselors have an ethical obligation to give clients the knowledge and right to accept or reject treatment that represents a particular theoretical orientation, especially if it deviates from established practice standards. Otherwise clients will assume that the treatment they are receiving derives from an accepted theoretical base or that it is the only available or appropriate choice.

Confidentiality

An other major tenet of ethical practice is to prevent unauthorized disclosure of client information. The assurance of confidentiality is a fundamental step in establishing the trust that is necessary for clients to work through difficult issues related to their sexual behavior. It is essential for counselors to clarify that confidentiality cannot be absolutely guaranteed. Otherwise clients may experience a deep sense of betrayal if information which they assumed to be protected from further disclosure is subsequently divulged by the counselor without their permission. Four ethical dilemmas involving confidentiality that commonly arise in the treatment of compulsive sexual behavior include:

Duty to Warn/Protect

Counselors have a widely recognized duty to warn or protect people whom a client places in imminent harm. When a client's history or proclivities involve risk of injury to others, such as in the case of a serial sex offender, the right to confidential treatment must be balanced by the need to insure the safety of others. At the beginning of the therapeutic relationship, a counselor must clearly convey the parameters of confidentiality and any safeguards that will be necessary to protect the welfare of at-risk populations. These may include the requirement that such a client quit a high-risk job, the use of polygraph or phallometric assessment, disclosure to members of the client's family or support system in order to enhance the sense of accountability, the agreement that law enforcement authorities will be notified if a client fails to follow the treatment plan, and the counselor's use of ongoing professional consultation to maintain objectivity. Although the extent of such precautions varies widely among counselors, whatever protective measures are established must be consistently monitored and enforced in order to maintain any value.

HIV

Courts have generally not applied duty-to-warn standards to situations in which clients place their sexual partners at risk of HIV infection (Houston-Vega and Nuehring, 1997). Balancing the counselor-client relationship with the protection of at-risk populations is a very complex and emotionally charged situation. Again, a range of approaches to this sensitive issue currently exists among counselors. Clinicians should discuss the exact nature of their HIV-related confidentiality policies with clients at the onset of treatment, remain current with state laws, educate clients about the seroconversion risks of their specific sex and drug practices, be prepared to speak directly about any concerns that arise during the course of treatment, offer to help communicate information to partners, and consult with colleagues as appropriate.

Minors

All states require counselors to report situations in which minors are in danger of harm, although specific state statutes differ (Corey, Corey and Callanan, 1998). Counselors sometimes may have difficulty distinguishing potential from probable risk. For instance, a client who downloads child pornography, despite professing a desire to stop doing so, may deny that children in his household are at risk of victimization, despite his transient sexualized thoughts about them. A counselor who decides to treat this client without notifying his spouse or the designated state reporting agency should document in the clinical record not only this decision but also a plan that addresses the well-being of the children. Similarly, at times clients may disclose information in which filing a child abuse report might seem to serve little purpose other than meeting a statutory requirement. Such a dilemma might emerge while counseling a family that is safely and effectively working through an isolated incident of incest between an adult and a minor. A counselor faced with such a situation will benefit greatly from consultation in order to maintain clinical objectivity.

Counselors treating minors who exhibit compulsive sexual behavior need to clearly establish the extent to which parents have the right to information that is disclosed by their children. A minor may be reluctant to discuss sensitive sexual issues if confidentiality boundaries are not clear, and may feel deeply violated if a counselor who is unclear on the limits of confidentiality later provides information to parents. Parents generally do have a right to basic information about the course of their child's treatment, although this does not equate to a right to full access to the clinical record (Corey, Corey and Callanan, 1998). Counselors should be knowledgeable of their state laws covering this topic, insure informed consent and seek professional consultation whenever questions arise.

Families

A major confidentiality concern that arises in counseling couples or families is how to deal with the emergence of secrets that so often accompany compulsive sexual behavior. For instance, a situation may arise during the course of marital counseling in which a husband who attends a session by himself informs the counselor that he's resumed cruising for anonymous sex but that he is currently unwilling to divulge this to his wife. A counselor who agrees to hold this information in confidence is colluding with a toxic dynamic that perpetuates an unhealthy cycle of secrecy. Yet there is little ethical justification for a counselor to unilaterally disclose information which a client had reasonably presumed would be kept confidential. To further complicate the situation, a counselor who threatens to discontinue treatment as a way to coerce a client into disclosing such information risks the charge of abandonment. Whatever policy a counselor decides to use for handling such difficult situations should be thoroughly discussed with each family member at the beginning of the counseling relationship so that all clients are aware of the consequences of disclosure (Corey, Corey and Callanan, 1998).

Maintaining Appropriate Boundaries

The next core concept of ethical counseling involves the complex area of maintaining appropriate professional boundaries. This topic is especially relevant when treating compulsive sexual behavior since such clients almost invariably bring to the clinical setting an extensive history of distorted boundaries. Most counselors are aware of the general prohibition against developing relationships that exist independently of the therapeutic role. Examples include providing clinical services to a friend or pursuing business or social interactions with clients outside of the clinical setting. Such dual relationships risk the impairment of a counselor's clinical objectivity or the unintentional exploitation of a client's dependence (Pope and Vasquez, 1998). Yet some subtle boundary issues that may unwittingly undermine a client's sense of safety are less clearly avoided.

Counselor Self-Disclosure

Clients may ask about their provider's marital status, sexual orientation, religious affiliation, and so on. Strategic use of counselor self-disclosure requires a deft therapeutic touch in order to facilitate emotional connection with a client while maintaining appropriate clarity of roles. A counselor should reveal intimate personal information only when doing so is clearly relevant to the client's treatment goals. The counselor must tailor such information to the client and closely attend to how this disclosure affects the relationship (Bloomgarden, 2000). Regular consultation with experienced colleagues and supervisors insures that disclosure doesn't shift to meeting the counselor's rather than the client's emotional needs. One helpful guideline is for a counselor to openly reference a personal life problem only after the difficulty has been resolved, and not while it is an ongoing issue (Hunter and Struve, 1998).

Touch

The seemingly simple act of touch conveys a variety of ethically ambiguous messages, especially with clients whose compulsive sexual behavior often reflects a childhood history of physical or sexual abuse. Used in a conscious and responsible manner, touch can orient, contain and nurture distraught clients and can model non-sexual physicality as a healthy dimension in relationships. As is true for all therapeutic techniques, ethical touch must be directly connected to a client benefit and be authorized by the client's informed consent. A counselor who touches a client must have a highly developed sense of boundaries and a solid knowledge base about the clinical consequences of touch, and must utilize physical contact only in the context of a mature therapeutic relationship where a full discussion of its effects is encouraged. Touch is generally not ethically appropriate if the recent focus of clinical discussion has involved sexual content (Hunter and Struve, 1998).

Sexual Attraction

Despite the widespread agreement that sexual contact with a client is an unequivocal ethical violation that can result in profound emotional damage, it is not unusual for counselors to occasionally experience some degree of sexual energy involving clients (Pope and Vasquez, 1998). Clients with sexually compulsive dynamics are likely to eroticize a wide range of interpersonal dynamics and may use seduction as a protective defense against the intimacy of the therapeutic setting. A counselor's risk of encountering erotically charged interactions with this client population is therefore likely to exceed the general clinical norm. Reluctance within the counseling profession to acknowledge and discuss the existence of sexual feelings toward clients can undermine the successful identification, understanding and redirection of these feelings when they emerge. Although transient sexual feelings are not in themselves either unethical or abnormal in the context of an intimate therapeutic relationship, intense preoccupation or sexual fantasies involving clients are clear indicators that a counselor has an ethical need to actively utilize open and on-going consultation and supervision.

Recovery Boundaries

It is not uncommon for experienced counselors to specialize in the treatment of compulsive sexual behavior after successfully facing a similar struggle in their own lives. Counselors with this type of personal history can encounter some specific ethical risks that require safeguards in order to protect the clinical integrity of the therapeutic relationship. Counselors who consider themselves to be "in recovery" often have a deep personal understanding of their clients, are able to demonstrate exceptional empathy, and may feel readily empowered to confront clients' self-defeating behavior. However, such counselors can risk excessive zeal and a tendency to overidentify with the treatment approach they personally found successful (Johnson, 2000). For instance, counselors who are strongly 12-step oriented may discount non-addictive models of sexual compulsivity, such as cognitive-behavioral theories, which risks placing clients into a one-size-fits-all philosophy of care.

Although a counselor who discloses a personal recovery experience may offer clients hope and understanding and help reduce shame by modeling an authentic self, unrestrained disclosure has clear risks. If used indiscriminately such counselor transparency may feel too intrusive, distracting, or unexpected for the client to integrate, and may generate unrealistic expectations or a sense of inadequacy (Bloomgarden, 2000). Counselors should reveal information about their personal journey toward healthy sexuality only in as much detail as is necessary to meet a clinical need that cannot be gained any other way.

It is extremely problematic from an ethical perspective for a counselor to attempt to assist clients in overcoming compulsive sexual behavior while unsuccessfully fighting the same battle. There is no definitive length of time for a counselor to be free from out-of-control sexual behavior in order to demonstrate personal competence to treat others. From an ethical standpoint, however, counselors with less than several years of recovery time require heightened consultation and supervision in order to address situations in which the counselor's objectivity may be challenged due to the existence of clinical issues that mirror the counselor's personal experience.

Although sustained abstinence from sexual acting-out is an inescapable ethical responsibility, relapse is an ever-present potential for such a pernicious and subtle set of behaviors. A counselor who reverts to a previous pattern of compulsive sexual behavior faces a host of ethical dilemmas, including whether to limit, suspend or terminate clinical duties. Abruptly withdrawing services from clients due to this (or any other) form of counselor impairment is likely to be deeply disruptive to the client's healing process (Bissell and Royce, 1994). Clients in such situations must be given the opportunity to continue counseling with other providers. No answer to the problem of counselor relapse is completely satisfying. In this regard the difference between a temporary "slip" that can result in increased self-awareness and unrestrained relapse is useful in determining a counselor's overall level of clinical impairment.

All counselors who are in recovery must establish whatever safeguards are necessary to insure the maintenance of a personal program of sexual sobriety. This may include establishing boundaries around support group meetings that clients are asked not to attend. Counselors in 12-step recovery should never sponsor their own patients or chair meetings where they are employed (Bissell and Royce, 1994). In addition, the importance of on-going participation in open and honest supervision is paramount for recovering counselors.

Supervision

The next core concept of ethical clinical practice is for counselors to receive adequate supervision and peer consultation. Counselors gain enhanced clarity of focus by discussing formulations, interventions, reactions and inevitable difficulties with supervisors and colleagues. There is also a need for exceptional levels of supervision and consultation for counselors who are working on the fringes of either personal competence or established theory (Corey, Corey and Callanan, 1998). For example, a counselor who is excited about trying out a new technique learned at a conference should utilize supervision to insure that it is being successfully applied.

A relatively common difficulty arises when a supervisor lacks adequate experience or knowledge to offer relevant guidance in treating sexually compulsive behavior. In such situations a counselor should seek to develop a process for obtaining specialized peer consultation. Informal telephone and e-mail networks can be fairly easily established by utilizing contacts made through professional affiliations such as the National Council on Sexual Addiction and Compulsivity (NCSAC).

The effectiveness of both supervision and peer consultation is dependent on the counselor's willingness to make the details and rationale of a clinical decision available for review. A counselor who does not have access to such feedback and guidance may unconsciously use selective inattention and rationalization when confronted by an ethical predicament. A useful method for gaining clarity in the absence of consultation is for a counselor to document in the clinical record a summary of the ethical dilemma at hand as well as any action that is taken in response to it.

Clarity of Values

Counselors, like all people, are influenced by the myriad variables which constitute cultural identity, including age, gender, ethnic identification, sexual orientation, physical capacity, education, religion and economic status (Corey, Corey and Callanan, 1998). The influence of cultural identity on personal values inevitably enters into the dynamic of counseling. Most ethical codes of conduct reference the importance of remaining sensitive to the influence of individual and cultural values on the counseling relationship. Counselors do not need to hold values that are identical to their clients in order to be effective change agents, but "the least we can do ethically is to be honest about our own biases and to make them a part of the conversation" (Coale, 1998, p. 86).

Counselors should continually evaluate the extent to which their conceptualization of compulsive sexual behavior either transcends or reflects cultural norms. Some of the many varieties of human sexual expression may violate a counselor's personal sense of propriety. A married heterosexual counselor may consider frequent sadomasochistic behavior practiced with multiple partners and fetish objects to be a clear indicator of pathological compulsivity. Counselors who label as diagnostic any behavior that deviates from a monogamous heterosexual standard are prone to unwittingly become agents of social control, enforcers of dominant cultural norms rather than facilitators of human potential. Frequent consultation with colleagues who represent various theoretical and cultural orientations is extremely valuable in preventing clinical 'tunnel vision'.

It is beneficial for counselors to take the time and energy to clearly articulate their ethical guidelines to clients, both verbally and in writing, rather than relegating ethical considerations to the tacit background of the therapeutic relationship. Clients with a history of compulsive sexual behavior have often experienced a lack of integrity in their relationships with others. A counselor who openly communicates and then consistently abides by clear ethical standards is modeling the effort and commitment that is necessary to maintain a principled relationship with another human being. Responding appropriately to ethical dilemmas encountered in the treatment of compulsive sexual behavior is a complex task that cannot be taken for granted by even experienced clinicians. Many situations arise which are not neatly addressed in formalized codes of conduct. Counselors must operate from an internal process that structures ethical decision-making along a variety of dimensions. The guidelines presented here are by no means exhaustive, but can serve as a useful means for evaluating the proper ethical stance to take in dealing with clients and situations that can often be difficult to address.

References

Bissell, L. and Royce, J. (1994). Ethics for Addiction Professionals. Center City , MN : Hazelden.

Bloomgarden, A. (2000). Self-disclosure: is it worth the risk? The Renfrew Center Foundation Perspective, 5 (2), 8-9.

Coale, H. (1998 ). The Vulnerable Therapist: Practicing Psychotherapy in an Age of An xiety. New York: Haworth .

Corey, G., Corey, M. and Callanan, P. (1998). Issues and Ethics in the Helping Professions. Pacific Grove , CA : Brooks/Cole.

Houston-Vega, M. and Nuehring, E. (1997). Prudent Practice: A Guide for Managing Malpractice Risk. Washington , DC : National Association of Social Workers Press.

Hunter, M. and Struve, J. (1998). The Ethical Use of Touch in Psychotherapy. New York: Sage.

Johnson, C. (2000). Been there, done that: the use of clinicians with personal recovery in the treatment of eating disorders . The Renfrew Center Foundation Perspective, 5 (2), 1-4.

Pope, K. and Vasquez, M. (1998). Ethics in Psychotherapy and Counseling: A Practical Guide . San Francisco : Jossey-Bass.