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Book Forum: Forensic Issues   |    
The Wounded Healer: Addiction-Sensitive Approach for the Sexually Exploitative Professional
Am J Psychiatry 2000;157:848-850. doi:10.1176/appi.ajp.157.5.848
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Cleveland, Ohio

by Richard Irons and Jennifer P. Schneider. Northvale, N.J., Jason Aronson, 1999, 252 pp., $35.00.

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The prohibition of sex between physician and patient is at least 2,500 years old. It matters little that a few ethical gray zones exist, that most sexual boundary violations go unreported, and that many patients do not claim damage. Such sex can destroy the doctor, the patient, and those close to them as well as tarnish the profession. Physicians and patients who collude in these surreptitious behaviors live with shame. Both are usually aware of the subtle evolution of the behavior, their personal motives, and their opportunities to prevent the sexual behavior. When most of these relationships come to light, they are simply summarized as sexual exploitation of the patient. The motives of the reporting person are ignored. The errant professional is held responsible and defined as bad, naive, or sick. These professionals are the important subject of The Wounded Healer.

During the 1980s, state medical boards and religious organizations chronicled a dramatic increase in accusations of professional sexual exploitation. They consulted mental health professionals. The basic question was, Why would this highly educated person devoted to the welfare of others risk profound psychological, familial, social, professional, and financial consequences?

In answering this question, Richard Irons and Jennifer Schneider begin by replacing the common language of sin, guilt, and forgiveness with the vocabulary of diagnosis, acting out, and defense. In assuming a psychiatric perspective, they take on its many limitations. For example, psychiatry has not sufficiently considered human frailty. People have a difficult time living up to standards of acceptable behavior. We violate people’s trust in many ways—by cheating, by committing crimes and misdemeanors, by our failures as parents, for instance. After we violate trust, we often seek understanding and redemption. Doctors are no exceptions. If their inability to live up to medicine’s ideals is due to a general human frailty insufficiently captured by psychiatric disorder, we may need to think more about the concept of frailty.

The topic of sexual exploitation of patients is too complex for science. In its place, psychiatry employs three tactics: 1) we explain the boundary violations with diagnoses (e.g., alcoholism, major depressive disorder, character disorder); 2) we speculate that succumbing to sexual temptation occurred because of a vulnerability from the interaction of the present (e.g., unhappy marriage, large debt) and the past (e.g., early maternal death, alcoholic father’s infidelity); 3) we theorize using established or creative idiosyncratic formulations (e.g., a man must learn to accept the feminine in himself).

Clinicians aspire to remain compassionately nonjudgmental and helpful even when the patient has transgressed against this fundamental prohibition. We have a difficult time concluding that the patient has simply behaved badly. We prefer "sick" or "naive" and mechanistically invoke unconscious processes. As a result, we risk blinding ourselves to our professional patients’ continuing self-protective dishonesties. Irons and Schneider teach that the accused professionals routinely deny, minimize, and rationalize what they have done. We are loath to state that these patients are lying. Similarly, clinicians are on guard against punitiveness, even though something tells us that the doctor, clergyman, or teacher needs to be punished. We at least have an out here: others are in charge of punishment. Sometimes we get caught up in thinking that physician-patient sex is explained by the unique strains and dynamics of professional life. Finally, we can limit ourselves by losing sight of how we generate face-saving explanations about how sickness creates bad behavior. We hesitate to conclude that the patient’s bad decisions created his or her sickness. Even when errant patients know better, they remain silent.

The authors report on their combined experience with more than 300 errant professionals (largely physicians). They are convinced that at least half of these people suffer from sexual addiction. "A sexual addict is a person who is obsessed with some type of sexual behavior, and whose behavior is compulsive and continued despite adverse consequences" (p. 35). Irons’ systematic study of this problem gathered information from 5-day inpatient evaluations of 137 individuals between 1990 and 1993. He and his staff focused on answering five questions: 1) What psychiatric diagnoses are present? 2) How does the professional’s painful past relate to the misbehavior? 3) Is the individual professionally impaired? 4) What is the prognosis for reoffending? 5) What treatment should be offered? They combine the answers into an innovative paradigm that describes six archetypes of sexually exploitative male professionals, each with a different profile on these five questions. The archetypes are the naive prince, the wounded warrior, the self-serving martyr, the false lover, the dark king, and the madman. After lengthy descriptions of each archetype, the authors provide a succinct and useful description of seven stages of rehabilitation. The book ends in a discussion of life processes and the importance of spirituality to mastering hubris. Jungian sensibilities abound as the language returns to forgiveness and redemption.

Although the authors’ ideas are often reasonable, their presentation distracts from their wisdom. They overuse chivalric imagery. "He has been told he has potential, and has received inspiration from the learned warriors and professional heroes that he desires to emulate. These are not storybook figures from fairy tales; they are flesh-and-blood giants who stride through the corridors of power and strength, wisdom, and action in the course of service in his professional fortress of learning" (p. 122). No arguments against an emphasis on addiction can be found. The methods used in their evaluations are not well described. Psychometric tests are not defined. Their case histories often fail to clearly illustrate their point—they eventually tell the reader what was illustrated a page or so later. The clinical decisions about their patients’ impairment, prognosis, and treatment seem arbitrary because they do not flow from the material in the histories.

The authors fail to share the criteria used to identify those who were unable to practice (75% of the group studied). We are left to imagine that some men were declared impaired for public safety reasons, others because their medical judgments were terrible, others because the authors feel that psychotherapy would not penetrate their defenses without time away from practice, others because punishment was indicated. Psychiatrists can easily accept the notion that a man may qualify for axis I and II diagnoses and still competently conduct a family practice, practice psychiatry, or be a pastor. Similarly, the reader is left to trust the authors’ judgments that 53% of the subjects required inpatient therapy after assessment. Irons and Schneider emphasize that 80% of their cases were victims of physical, emotional, or sexual abuse, emotional incest, or abandonment as children without questioning how many nonoffending professionals have been victims of this same wide spectrum. Their assumptions about causality and treatment are worthy of further examination and debate. They do not wonder if there is a referral bias in having 35 state boards refer some of their errant professionals to two well-known addiction specialists.

The authors are undoubtedly correct that some errant professionals may be usefully thought of as sexually addicted. Their descriptive ideas are worthy of consideration—particularly their notions of a male’s relationship to the feminine in himself and the fruitless aspirations of those who become addicted. Their sophistication is not evenly felt throughout the book, however. It is only in the last chapter, for instance, that the reader learns that Irons and Schneider know that "there are at present no published studies that portray the natural course of professional misconduct and sexual offense. Nor are there any controlled studies that compare treatment approaches for professional sexual offense" (p. 213). Had they begun the book with these ideas, they might have edited out the tone of certainty that is conveyed by the recurrence of words like "only" and "must" when treatment is being discussed.

We should not expect that any large case series, even when presented by people with talent and conviction, can generate anything more than hypotheses to be tested with the methods of clinical science. One of the book’s other contributions is its helpful discussion of psychological growth. The authors emphasize that maturity follows from reality’s deflating impact on the ego. This allows addicts to appreciate the larger forces of life that humble, redeem, and ultimately enrich them. One does not have to be a recovering addict to feel this impressive power of reality. It easily comes to all authors after they commit to paper their ideas about the causes and necessary treatment of human behavior.




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