Professional Sexual Misconduct in Institutions: Causes and Consequences, Prevention and Intervention

by Werner Tschan, MD. Hogrefe Publishing, Boston, MA, 2014, 216 pages, $49.00 (paper).

Sexual misconduct by professionals such as physicians, therapists, educators, clergy, lawyers, sports coaches, or military personnel, has received a lot of attention lately. It is clearly much larger problem than previously thought or imagined. The (mostly) media attention focuses on the stories of the victims and possible punishment of the perpetrators, but not much on what to do about this widespread problem. Werner Tschan, a Swiss psychiatrist, has devoted most of his professional life helping victims of professional sexual misconduct (PSM). However, as he mentions in the preface of his book, he has also been helping the offenders and realized that there is an "urgent need for the development of treatment and rehabilitation programs for offender professionals" (p xi). As there was really no comprehensive text addressing all aspects of this topic, Dr Tschan put together all of the information on what to do about PSM in this small volume. "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 opportunities and also due to the vulnerability and dependency of the clients on their professionals" (p xi).

The reader may ask about the meaning of the term professional sexual misconduct. According to the author, "PSM includes any form of sexualized behavior committed within a professional role, whether it is penetration, sexualized behavior in broader sense (hands-on, hands-off offenses), or sexualized remarks" (p 46) (sexualized remarks include attempted dating). "Boundary violations constitute one form of disruptive professional behavior, and, in most jurisdictions, they are considered to be a crime" (p 27). Both of these concepts, especially the one of boundary, have evolved over the years and are now founded on both legal requirements and professional standards (p 1).

The book consists of 12 chapters addressing issues such as understanding survivors’ reactions with a discussion of the attachment theory; how PSM happens; PSM in various disciplines; impact of PSM on survivors, institutions, and professionals; treatment of survivors; why professionals commit sexual offenses; prevention of PSM in institutions; boundary training; and assessment and rehabilitation of affected professionals—basically, all that one can and needs to know about PSM. The book brings together materials and information from various countries, and its recommendations and guidance could be used anywhere. In the first chapter, Dr Tschan points out that, interestingly, in Europe and Asia the implementation of effective laws against PSM is around 20-25 years behind that in North America, Australia, and New Zealand! Some European countries, namely Germany, have been rectifying this discrepancy lately.

Below, I highlight several particularly interesting sections of the book in order to illustrate its comprehensiveness:

• The discussion of the attachment theory and PSM states that sexual offenses are always embedded within a human relationship and thus "sexualized violence is always a relational offense" (p 32).
• The chapter on PSM definition reminds us that "the transgression of professional boundaries takes place in step-by-step process . . . and fantasies are the fuel for committing PSM" (p 47). However, the author points out that most of us have probably had unacceptable fantasies, yet most of us also have not acted them out. This chapter also discusses the issue of punishment versus treatment of offending professionals. Some may be given a chance after enrolling in treatment and boundary training; however, those working with children and juveniles should never be allowed to return to their profession when allegations were substantiated (p 69).
• The chapter on PSM in various disciplines proposes guidelines for physical examination that would clearly define the physical boundaries between the professional and the patient.
• The chapter on overlap with workplace violence includes a diagram of internal decision-making processes in cases of PSM and sexual harassment.
• The chapter on treating survivors outlines the healing journey—from silence, shame, guilt, and denial to disbelief, realizing, finding help, processing, integration, and finally overcoming the trauma of PSM.
• The discussion of why professionals commit sexual offenses presents a model of how PSM takes place in a step-by-step process (fantasies, feelings, needs, urges—ideation, crossing the line—preparation, grooming—sexual offense—maintaining the silence).
• The chapter on prevention of PSM in institutions points out that for effective prevention, "reporting is a prerequisite condition" (p 137).

I found the chapters on boundary training and on assessment and treatment of affected professionals to be the most informative. Dr Tschan emphasizes that the paradigm has shifted: "The treatment of sex-offenders is seen as the most effective way of protecting potential further victims" (p 151). He also writes that boundary training (a semistructured manual-based treatment program consisting of 24 modules) "is not a punishment, rather it should be considered as help to re-establish professional competence, making it therefore a rehabilitative program" (p 153). The chapter on assessment and treatment points out that not everybody is able to benefit from rehabilitation, nor may all individuals accept it, and that it is better if sexual offender and treating professional are not from the same profession because of the danger of collusion. Finally, the author emphasizes that contacting of the victim by the offender must not occur.

This is a very informative, comprehensive, and useful book. It would be an invaluable resource not only for those treating victims of PSM and professional offenders, but also for administrators and leaders who develop policies and preventive measures for professional sexual misconduct.

Richard Balon, MD

rbalon@wayne.edu

Author affiliations: Wayne State University School of Medicine, Detroit, Michigan.

Potential conflicts of interest: None reported.

J Clin Psychiatry 2015;76(7):e895

dx.doi.org/10.4088/JCP.15bk09800

© Copyright 2015 Physicians Postgraduate Press, Inc.