Ethical Dilemmas Related to Disclosure Issues: Sex Addiction Therapists in the Trenches

By Jennifer P. Schneider and Barbara Levinson

Sexual Addiction & Compulsivity, 13:1-39, 2005.

Abstract

Therapists who treat sex addicts are often faced with ethical dilemmas.  Almost every therapist has encountered some unexpected situation that has put us in a quandary and by its very nature calls for decisions that could challenge our code of conduct.  In this article the authors describe several types of ethical dilemmas related to disclosure.  The focus is on revelations made by the patient, the therapist or a third party.  Disclosure was chosen as a focus of this paper because of to its potential consequences and the possible risks when handled inappropriately.  The authors illustrate their findings with insightful examples and give a broad range of possible solutions while describing the potential positive or negative outcomes. They give their opinions and their collective wisdom based on their own research and clinical practice.  Several therapists also contributed to this article by generously stating their experiences.

Introduction

Ethics as discussed in the following paper relates to a code of conduct that should be followed by all treatment providers.  It implies the highest standard of care and protects the community and the treatment provider. Some believe it implies the difference between right and wrong.  Ethical issues are inevitable when counseling sex addicts. The possible scenarios are so diverse that it is likely every therapist has faced an unanticipated ethical dilemma and has had to work out a solution in the moment. It would be far better to have given thought to these quandaries in advance and to have some guidelines for one’s actions.   This paper describes various categories of ethical dilemmas involving disclosure of secrets, and presents the authors’ recommendations for dealing with them.  Although many of these dilemmas have both ethical and legal dimensions, our focus is on the ethical aspects, which often are less clear than are legal guidelines. Moreover, legal mandates may vary with the state and country in which the therapist practices, so that the therapist is advised to become knowledgeable about the laws of his or her place of practice.  The solution to ethical dilemmas, however, is more generally applicable.

This paper is based in part upon a workshop given by the authors at the October, 2004 national conference of the Society for the Advancement of Sexual Health (SASH), and also in part on a similar workshop presented at the same conference a year earlier by one of the authors (JPS) together with Bill Herring.  The focus of both workshops was to work out practical solutions to clinical problems involving disclosure of secrets.

Review of the literature

Relationships between helping professionals (such as physicians, counselors, therapists, lawyers, ministers, or teachers) and those they serve have always been seen as having special significance and meaning. In each case, there is a power differential, and the person in lesser power assumes that the professional will act in the best interests of the one who is to be helped. In each profession, unfortunately, there have been many cases in which this was untrue. For this reason, professional organizations have increasingly been concerned with clarifying their position on ethical issues between professional and client, and most have in recent years issued detailed position papers spelling out the appropriate role of the professional. Model Rules of Professional Conduct have been published by the American Bar Association, American Medical Association, and American Psychological  Association (2002), and American Psychiatric Association (2001) and National Board of Certified Counselors (2002). Many books and articles have been written to address various ethical issues in the helping professionals, such as sexual relations and other boundary violations between professional and client (patient, parishioner, student), for example, Irons and Schneider (1999); the role of touch in psychotherapy, for example Hunter and Struve (1998); disclosure to patients about medical errors (Mazor, Simon, & Gurwitz, 2004; Gallagher et al, 2003); and a feminist perspective on ethical decision making in therapy, for example by Rave and Larsen (1995). Regarding specifically the ethical issues involved in the area of disclosure of secrets, Corley and Schneider’s book Disclosing Secrets: When, to Whom, and How Much to Reveal (2002) discusses some of the dilemmas to be addressed in this paper.

An excellent guide to the various core concepts of ethical practice in counseling sex addicts was presented by Bill Herring (2001), who cogently discussed ethical issues in the areas of informed consent, the therapist’s competence, confidentiality, duty to warn/protect, HIV disclosure, when to report sexual behaviors with minors, confidentiality issues regarding families of clients, maintaining appropriate boundaries, counselor self-disclosure, touch, sexual attraction, recovery boundaries, supervision, and clarity of values. The reader who wishes to read about these concepts is referred to Herring’s paper. 

Ethical Dilemmas

In an attempt to make more coherent the diverse quandaries the therapist may encounter regarding disclosure of secrets, we have organized the discussion around the source of the information, which may be the client, a third party, or the therapist. Case examples will illustrate the dilemmas summarized in Table 1

Table 1:  Ethical dilemmas regarding disclosure of secrets in therapy

1. Information originating with the client.
   
   1. One client in couples’ counseling discloses to therapist an affair or another secret not known to the partner
   2. Client discloses behavior that has harmed, or may harm another person, adult or a minor; such as a  having unprotected sex despite positive HIV status, or sexually exploiting a patient, client, or parishioner in the course of a professional relationship.
   3. Client discloses illegal behavior.
   4. Client discloses boundary violations with a therapist seen previously.
   5. A family member requests information about a former client, now deceased.
2. Information originating with a third party (another client, another therapist, law enforcement, 12-step program)
   
   1. Information indicating the client is lying.
   2. Information indicating the client is at risk of harming others. 
3. Information originating with the therapist 
   
   1. Therapist’s beliefs – politics, ethics, etc
   2. Therapist’s addiction history
   3. Therapist’s sexual orientation
   4. Other

I. Information originating with the client.

a. One client in couples’ counseling discloses to therapist an affair or other secret not known to the partner.  

The classic issues involving disclosure or nondisclosure of an affair during couples counseling have been discussed in the marriage and family field, where the recommendations are typically situational. For example, noted affairs expert Shirley Glass wrote, “It is inappropriate to conduct conjoint marital therapy when there is a secret alliance between one spouse and an extramarital partner that is being supported by another secret alliance between the involved spouse and the therapist.” Nonetheless, she is willing to see the couple without addressing the affair if the affair is first terminated (Glass & Wright, 1992).  

In considering the effect of disclosure in a situation when addiction is not present, the answers to the questions below can help a therapist decide what recommendations to make about disclosure (Corley & Schneider, 2000b):

• Is the affair over?
• Does the client still have any contact with the affair partner?
• Does the client still have strong feelings about the affair partner?
• How did the affair impact the couple’s relationship?
• What lies were used to cover up the affair?
• Is this the only affair the client had, or was there a recurring pattern?
• Does the affair have any current impact on the couple relationship?
• How comfortable does the client feel about ongoing concealment?
• What is the meaning for the client of disclosing or not disclosing?
• What does the client believe will be the positive as well as negative consequences of disclosure (to himself, to the spouse, to the relationship?)
• What does the client believe will be the positive as well as negative consequences of continuing not to disclose? 

The above list does not, however, mention the impact on the therapist of doing couple counseling while holding such a secret. This issue will be discussed in a separate section below.

When doing the disclosure there are many different frameworks that therapists adhere to, depending on their training and experience.  Some ask the addict to reveal broad general outlines and others ask him to get very specific regarding types of sexual activity that took place, the financial outlay, number of times the particular activity occurred, the time frames and the lies the addict told to cover the behavior. 

Sometimes the therapist asks the addict only to admit sexual behaviors that took place since the couple knew each other whereas other therapists may encourage disclosure of relevant information of their entire sexual history. This may be an area that can be quite shameful for the addict and very painful for the partner.  Consider the addict who may have had sexual contact with a younger sibling and is afraid to tell his partner for fear  the spouse may think he  will abuse their own children. It is also a dilemma for therapists practicing in a state that has laws requiring the therapist to report sexual abuse, no matter what the time frame. This is true, for example, of Texas, yet the Texas criminal code sets the statute of limitations as 10 years after the victim is 18.  What should the therapist do ethically in the face of these different statutes? 

We believe that, barring unusual circumstances, revealing past sexual behavior will not only enlighten the partner but additionally, give them the information they need to accurately process the information. For example, when a person learns that their partner is a sex addict, the person will usually ask if the addict might be a child molester. It is best to deal with this directly.  Another area of concern is the disclosing of same-sex addictive behavior, which can be another area of resistance for the addict.  The partner has a right to know about  preference.  It is another question that the partner usually asks and once again, it is best to discuss this openly.

In the context of addictive sexual disorders, there are two unique factors that significantly impact the disclosure process:

1. The sexual acting out has been repetitive and the betrayal and lying egregious.  Even when the presenting problem is a single affair, there generally is a hidden history of other affairs or additional sexual acting out.
2. The most widely used model of recovery from addiction, based on the Twelve Steps of Alcoholics Anonymous, is confusing. On the one hand, the program requires “rigorous honesty.”  Disclosure is often an aspect of making amends, beginning the process to right wrongs. Yet, Step Nine cautions against making amends to those who have been harmed “when to do so would injure them or others.” (Alcoholics Anonymous, 1953).” Thus, it would seem that at times honesty is not the recommended course. (Corley & Schneider, 2002(a).

Addiction authors have generally supported disclosure, but the ethical issues remain. For addiction counselors, the key ethical issues facing the therapist who learns of a client’s secret are:

• Effect on the clients if the secret is revealed
• Effect on the clients if the secret is not revealed
• Effect on the therapist and on the therapeutic process if the secret is not revealed.

Effects on clients if the secret is revealed

Disclosure is understandably a very stressful process for both sex addicts and their partners. Addicts report initial worsening of the couple relationship, guilt and shame, anger from the partner, loss of trust by the partner, a cessation of the sexual relationship, and damage to other relationships such as with children, parents, or friends. Partners report initial worsening of the couple relationship, depression and even suicidal thoughts, attempts to compensate for the pain with acting-out behaviors such as drug and alcohol use and sex, loss of self-esteem, decreased ability to concentrate and/or function at work, feelings of shame and guilt, distrust of everyone, anger and rage, fear of abandonment, physical illness, and lack of sexual desire (Corley & Schneider, 2002b).

At the same time research shows that over 80% of partners and more than 60% of addicts report that at the time of disclosure they felt it was the right thing to do. With additional time in recovery, 96% of addicts and 93% of partners concluded that it was the right thing to do. (Schneider, Corley, & Irons, 1998). This was true even though a majority of partners threatened to leave at the time of disclosure. Positive outcome of disclosure for addicts included:

• Honesty
• End to denial
• Hope for the future of the relationship
• A chance for the partner to get to know the addict better
• A new start for the addict, whether in the same relationship or not.
• Decrease in stress

For the partner, the most significant positive outcomes from disclosure were:

• Obtaining clarity about the events of the relationship
• Validation that they are not crazy
• Hope for the future of the relationship
• Finally having the information necessary to decide about one’s future

Most therapists agree, however, that there are times when it’s better for the client not to reveal the secret to the partner.  Sometimes there are gray areas, and one therapist may differ from another on whether disclosure (full or partial) would be appropriate. Some such situations might be:

• When the spouse is physically or mentally ill and the therapist agrees that the spouse would be unable to utilize or deal with the information.
• When the secret would cause great damage, such as the potential for physical violence, or if the affair involved a close family member such as the spouse’s sister and disclosure might destroy the extended family. (Each decision regarding family members must be considered cautiously. There are times when disclosure is advisable, and times when it would be extremely detrimental).
• When the behavior occurred long ago, the client has worked it through, the current relationship was not affected, and the information would be very upsetting to the spouse. 
• When the spouse’s religious or other beliefs would preclude any willingness to reconcile if such information were divulged. 

Disclosure vs. nondisclosure is a very difficult topic. We believe there are only a handful of situations where non-disclosure would be the best course of action. In general, the addict is likely to use every excuse not to tell, and the therapist must be able to discern legitimate concerns from the addict’s generalized need to maintain secrecy.  A decision not to disclose needs to be thoroughly evaluated, the client’s motivation assessed, and the likely outcomes considered.

Effects on the sex addict client if the secret is not revealed:

Part of the disease of addiction is the tendency to lie and keep secrets. This can become such an integral part of the addict’s behavior that he or she may lie even about things that don’t matter.  Recovery, therefore, urges “rigorous honesty.”  The general principle, is that for the addict’s recovery, it’s a good idea to disclose secrets. If the addict decides not to reveal a particular secret to the partner, the therapist and addict need to discuss the effects on the addict of not revealing the secret. Does the addict feel shame about the non-disclosure? Is the secret like the ”elephant in the living room” of the couple’s relationship, something that is not discussed but which clearly affects the couple? 

When the secret involves remote events, the therapist should discuss the context with the client.  But, what will be the consequences of not telling? Is the addict going to feel  remorse by withholding something from the spouse? Ask the addict what he or she thinks about the disclosure. What will be the consequences of disclosure, and of non-disclosure?  Clarify with the addict, and then decide whether to do it.  As one therapist explained, I usually do encourage the addict to disclose. I make the point that this is a disease, it’s not about the spouse at all, and it gives the spouse a chance to see how big a problem this has been all along. It’s not just about her, or him, and he or she gets to make a decision on the basis of the truth, not just on part of the story.

Effects on the spouse if the secret is not revealed:

Over the duration of the sex addict’s disease, the spouse has usually been the recipient of multiple lies. Co-addicts become very reactive about being lied to.  In recovery, Schneider & Schneider (2004) advise the addict, “Be honest in the small things on a daily basis, and your spouse will be more likely to believe you about the big things.”  (p.116). For spouses to rebuild trust in the addict, rigorous honesty -- day after day – is essential. When couples in recovery go to marriage counseling, rebuilding trust is usually a major issue.

Staggered disclosure can be a big obstacle to rebuilding trust. When the addict claims initially to reveal all the relevant facts but actually withholds the most difficult information, such as an affair, partners report great difficulty in restoring trust (Schneider, Corley, and Irons, 1998). When the affair eventually is discovered or disclosed, as it most likely will be, partners report feeling betrayed and victimized all over again, and the gains made in rebuilding trust will vanish. It is much more beneficial for the addict to risk disclosing initially the broad outlines of all his or her acting out behaviors.

Additionally, it is likely that the truth will eventually come out, either in therapy or at home. When that happens, the deceived spouse will feel betrayed and victimized by the therapist, and the result may be a fatal compromise of the therapist’s ability to counsel her at all. 

Effects on the therapist and the therapeutic process if the secret is not revealed.

Significant ethical issues arise for the couple’s counselor who colludes with one member of the pair to keep a secret from the other. Brown (1991, p. 56) writes, “I believe that the integrity of the therapeutic process with couples depends on open and honest communication. Nowhere is this truer than with affairs. The therapist cannot be effective while beginning to collude with one spouse over the other. If a spouse tells her couple counselor that she suspects her husband has been unfaithful, and the therapist knows that this is in fact the case but is bound by confidentiality issues, the therapist may be able to do nothing more than ask, “What makes you think that?” and advise the partner to focus on herself instead of her partner. The ethical therapist is likely to find this an extremely uncomfortable, if not untenable, position.

Do I see them separately, together, or both? 

Different therapists have varying strategies to avoid the triangulation that results from holding a secret with one client against the other. Some therapists decline to have any telephone or personal conversations with only one partner. Others are willing to do this, but announce up front that any information divulged in these individual conversations will not be kept confidential from the spouse and will be open to discussion in the couple session. The advantage of such a stance is that the therapist avoids having to hold a secret given by one partner. The big disadvantage is that the efficacy of the conjoint therapy may be less than optimal because the therapist may be missing a large piece of relevant information, such as that one partner has an ongoing affair, or that one partner is not committed to working on the relationship.

In the ethics workshop, two counselors explained why working with only the information obtained from the client is a disadvantage: 

We only know what the client tells us. More than once, after the couple counseling was finished and the couple went through a divorce, I learned from the legal deposition that I hadn’t been aware of some very relevant information about the addict’s acting out that would have changed the way I would have counseled them. 

I’ve had clients where if I’d treated them without the outside information I obtained; it would have been no treatment at all.  In the end, it’s helpful to know.

Other therapists do meet individually with each partner, seeking to obtain as much information as possible. The advantage of this stance is that you are more likely to know the real story. The disadvantage is that you may find yourself holding a secret that you are ethically unable to divulge without the client’s permission. This situation is fraught with the most difficult ethical dilemmas the therapist will encounter. You will then need to be very careful in the way you counsel the couple in order not to reveal the secret.  You will need to have a constant observer in your head, monitoring everything you say. The situation can quickly become very complex. You will need to devote a great deal  of energy to having an inner observer who monitors what you say to the couple and what you can do with every piece of information you have.  Where did you get it? Are you breaking confidentiality? Can I say this or that?  It takes an enormous amount of concentration.

Some therapists who see individuals together and separately explain to them that if any secrets are told in the individual sessions, then the therapist will work with the client individually with the goal of facilitating disclosure to the partner. Some put a time frame on the individual work – perhaps 3 or 5 sessions. One of the authors (BL) explains: 

I do not put such a short time frame on this. There are times I do not give a time frame to the spouse in order not to put undue pressure on the addict before a therapeutic relationship can be established. I usually ask the spouse to write the questions they have for the addict so I can know what the specific concerns are.  If the addict refuses to reveal something that is of concern to the spouse, then I would continue to work with the co-addict and may even have the addict tell the partner that he is not ready to do a full disclosure. This way, I am able to keep a relationship with both parties and support them in their individual therapy.  If at some point the co-addict does not want to continue the relationship, I then help the addict to deal with the bigger ordeal, telling the truth or the breakup of the relationship.

If the secret-holding client is unwilling to disclose, then the therapist will decline to continue conjoint counseling.  In the ethics workshop, one of the authors (BL) detailed how she deals with this situation:  

I’m known in the community for working with sex addiction. A typical scenario is that a woman will phone and say, “I found my husband doing this or that. What do I do?” I talk to her before I see them, to be sure there’s no conflict of interest. Then I ask the woman to bring in her husband. If they come in together, I ask the wife to describe what’s been going on, I ask the husband to give his perspective. Then I tell them about the treatment I favor, which is a combination of individual, family, group, couple, and COSA and SAA.

I tell them that I will meet with them individually and that in those individual sessions there may be things that they may feel uncomfortable divulging in the joint session.  After that we’ll make a decision about how to proceed. I tell them I work two ways: There are times when I’ll see everybody and do everything, and there are times when I refer the co-addict out --- usually I keep the sex addict.  I tell them that the good news is that when I see both the couple and the individual, that I know everything. And the bad news is that I know everything. So you have to make a decision – If you opt to see me together, then complete honesty is the golden rule.  If you want to see me as a couple and you tell me something your partner doesn’t know and you say you’re not going to tell her, I’ll work with you for a period of time, but honest open communication is what I strive for. If a reasonable time passes and you are not willing to disclose any acting out or slips I will stop the couple’s therapy and tell you that I believe individual therapy is better at this time. To that end, we’ll have a disclosure contract before you even tell me any secrets. One of the reasons I’ll decide to stop couples therapy is if one or both or you has a secret. Do you want to see me under these conditions?

This automatically puts the patient in a therapeutic double bind. If the addict says he will not agree to this, then the wife is suspicious from the beginning. If he states that this is fine with him I then may say that a polygraph could be given in certain situations

All this is very time-consuming. I spend a lot of time on rules and structures, making sure, for example, that if one patient tells me the other told her that I said something in the individual session, I don’t validate her statement or take sides. That’s triangulating. It takes a lot of time if you’re seeing people separately, making sure this doesn't happen. I do it because it lets me know everything.

I usually see them individually first and do an assessment and get a relationship with each. I usually don’t start couples therapy immediately. I also have a group for men and women, and I might put each in a group immediately.  If the couple is in a real crisis at first and can’t contain themselves, then I’ll do some couples therapy and give them information. I do a lot of didactic work, explaining sex addiction, educating about anger, and trying to support the spouse while not shaming the addict.  Usually there is a lot of anger coming from the addict and a lot of denial.  If this occurs, the therapist faces the dilemma of not alienating the patient, yet holding him accountable. I try to get a commitment from the co-addict to go to COSA [or S-Anon]. This is difficult, because she often says “It’s not my problem,” so I have to do a lot of education.  Once I start couple therapy, I usually see them individually one week and as a couple the next.

Another therapist reported: 

To avoid holding secrets a therapist who sees clients both individually and as a couple needs to set up the rules in advance. Of course the rules may end up limiting the amount of information he gets. 

Another therapist stated: 

A therapist who sees clients together and also separately takes a slightly different twist, putting the responsibility squarely on the client:

This therapist seems to be walking a fine line, hinting in the couple session at things that were divulged individually, hoping to precipitate more honesty. 

After listening to these explanations, a therapist commented:

Another way of minimizing these conflicts was reported by a counselor who said:

What about the situation where the therapist has done individual counseling with a client who then seeks couples counseling from the same therapist? One psychologist reported:  

What is clear from the above comments is that despite the different approaches taken by various therapists, all are aware that confidentiality and other ethical issues complicate the work of couples therapists, especially those who see clients both individually and together. Therapists need to consider all these issues carefully in advance, before deciding on their therapy style and rules. In particular, they need to give careful thought to the benefits and costs of allowing a client to divulge sensitive information to them, and if they do not wish to put themselves at risk of possessing such information, how to minimize the chance that they will be caught in the middle. We believe that no matter what the therapist’s style, the therapy will be adversely affected if the therapist holds a secret that is relevant to the couple relationship and does not address it. 

b. Client discloses behavior that has harmed, or may harm another person: a minor; positive HIV status; or a client or patient in the course of a fiduciary relationship.

Child pornography

In contrast to the previous item, the responsibilities of the therapist who learns of actual or potentially harmful behavior are governed by laws (which often differ from state to state) as well by regulations of one’s professional licensing board.  It behooves all helping professionals to become familiar with the laws and regulations relating to mandated reporting of various behaviors.  In this section, however, we will focus on the ethical considerations of such disclosures rather than the legal implications.

Therapists all too often face ethical dilemmas when they learn of behaviors that can potentially harm others.  How do you balance your responsibility to the patient and the need for confidentiality, versus the potential harm if you do nothing? Whether or not the behavior is illegal, the ethical issues are real. 

One of the most common issues faced by sex addiction therapists’ concerns clients who disclose sexual feelings and behaviors related to children. In some situations the activities are illegal and must be reported; in others there is no mandate to report, but ethical dilemmas persist. For example, possession of child pornography is a felony that can lead to a prison sentence, but viewing child pornography is not.  Downloading or transmitting child pornography is a serious crime, but viewing it on a website is not a crime. Where does this leave the therapist who learns from a client that he spends many hours viewing child pornography? One therapist reported:

One of the authors (BL), who is experienced in working with sex offenders, commented: 

I do not know if this is appropriate to do.  I believe that some therapists without the proper training in this area may put themselves and the patient in jeopardy. 

When a patient comes to me because of thoughts or fantasies about children I do a very careful assessment. If the therapist does not have specific training in the area of deviant arousal or sexual offender assessment, the ethical thing to do would be to refer the client out.  If the patient is coming to you and in the course of history taking you discover that he is frequenting child porn sites, then the client must be told of the dangerousness of this activity and the possible legal ramifications.  If the patient is in denial and does not want to stop the behavior, then the therapist may have to weigh different options.  Is this patient at risk for offending behavior? Is the patient having fantasies that are ego-dystonic or ego-syntonic? Does the patient work or do activities that are high risk? Has the behavior increased in intensity? 

I am working with such a patient at this time.  He was referred by another patient who is sponsoring him in a twelve-step S program [for sex addiction].  This man was going to Internet sites and looking at child porn.  He has an extensive history of interest in young girls and has come close to inappropriate behavior.  I made a contract with him and got him to agree to stop all activities with children in his target age group. He is a teacher, but now only a substitute and he works with older-age students. He is reluctant to stop teaching altogether.   The dilemma is that he has not done anything that is reportable. 

I am continuing to work with him intensively.  I work with his sponsor indirectly, by insisting that he share WITH THE SPONSOR EVERYTHING and get his feedback.  I know the sponsor and trust that he will back up what I am telling the patient.  I also told the patient that if I thought he was escalating, I would do what I needed to keep the community safe and that I would tell him before I would report him.  I spent at least 2-3 sessions going over with him what I would report and what would be questionable. I had the patient sign the informed consent and other paper work that I use with a sex offender population before I told him I would take him on as a patient.  I also told him under what circumstances I would discharge him.

During the assessment I obtained information that makes it likely that a diagnosis of Pedophilia is appropriate. He has never had sex with an adult and is solely aroused by female children between the ages of 9 and 13. He loves children; he finds no other joy in life. He wants to be a youth counselor at a church. However, has been asked to resign from that position at two churches because of questionable behaviors.  When he asked if he could ever teach, I replied, “You might not ever be able to do that.” He got very depressed and we began dealing with his depression as well as helping him in developing adult relationships.  

It is very difficult to decide when to report if there has been no crime.  One must assess the level of risk to the community and decide whether confidentiality takes precedence of community safety. These are difficult dilemmas for the therapist and one must take all possible consequences into consideration before taking action. One cannot operate in a vacuum. Asking for input from other professionals is essential.

For this client, I would try to get him into inpatient treatment right away. Because of the addictive nature of the computer, and the high-risk situation, I’m not going to tackle it on my own. I’d leverage it the best way I can. I’d tell him, you’ve got to go inpatient, buy some time. Get a treatment team to lay out the parameters for long-term recovery.

Referring out is an excellent idea for a counselor who feels that a particular problem is beyond her depth.

Another case created a similar ethical dilemma:

The consensus seems to be that there are times when concern for the safety of others supersedes the therapist’s concern for client confidentiality or loyalty to the client.  And in the long run, the outcome of the therapist’s action may in fact be in the best interest of the client, as in the above example.  

Long-ago Behaviors

A therapist presented the following dilemma: 

A colleague, who works with sex offenders, responded: 

Positive HIV status

Nondisclosure of positive HIV status to the spouse or other sexual partner leads to another ethical dilemma for the therapist or healthcare professional. Here too, state laws differ. Some, citing the Tarasoff ruling (1976), mandate notification of sexual partners; others don’t. As summarized by the HIV Criminal Law and Policy project,  24 states have adopted statutes that criminalize exposure or transmission of HIV generally or specifically by at least some form of specific behavior such as spitting, donating blood, or sexual intercourse. (see http://www.hivcriminallaw.org/laws/hivspec.cfm) For example, Florida’s Title XXIX, Chapter 384, states:

What, then, does the therapist or health professional do who learns that a client or patient has not disclosed their HIV status to their sexual partner? If the client is on probation and his treatment with the therapist is mandated, the course of action is more straightforward. The treatment plan consists of full disclosure to whichever family members the provider believes it necessary to inform. The treatment plan at the outset can also specify no unprotected sex or high-risk sex.  If the client violates the treatment plan, then it’s rational to report him to the probation officer and notify the spouse or partner. Because offenders are very rarely honest, nor do they report when they are in violation of their treatment contract, the therapist needs to be very alert to signs of lack of follow-though. 

The situation is even more complex in the more typical therapy situation. One of the presenters (JPS), a physician, said,

The American Medical Association’s Code of Medical Ethics (150th edition) for physicians states (p.62):

The American Psychiatric Association’s Practice Guideline for the Treatment of Patients with HIV/AIDS states:

The Canadian Psychiatric Association, in their 2002 position statement, “The Duty to Protect,” stated:

In the United Kingdom, the guidelines are not definitive. In 2000, a report from the UK stated:

As the above report shows, in some situations the legal requirements and constraints on reporting may differ from the ethical. In the author’s opinion (JPS), it is unethical for a health care professional to knowingly permit one person to endanger another and to do nothing about it. It may be different for a licensed counselor or therapist, as some state laws and licensing board regulations specifically prohibit the professional from disclosing a client’s HIV status, even in cases of a duty to warn. One therapist’s solution is to routinely strongly encourage both addict and spouse to get STD testing, “because someone may have done something they’re not disclosing.” 

The American Psychological Association’s Code of Ethics (2002) states:

The National Board of Certified Counselors, in its 2002 revision of the Code of Ethics, states:

Although HIV infection is no longer a quick death sentence, AIDS remains a serious and potentially fatal disease whose containment requires life-long treatment with drugs that are expensive and have major side effects. Significant stigma exists for this disease, and infection with it can be an adverse life-changing event. Therapists’ opinions on their duty to warn is variable (Burkemper, 2002). Helping professionals need to take very seriously the consequences to other people who are in a sexual relationship with the seropositive client. 

Professional Sexual Misconduct

Another ethical dilemma concerning patient confidentiality versus harm to others occurs when the therapist learns of sexual misconduct by a professional. A therapist related,

While obtaining a sexual history from an impaired physician, I asked about frottage and he answered affirmatively. I thought he was going to tell me about an elevator incident or something similar, but apparently he had had sexual contact with patients while they were under anesthesia. I said, stop! Because this was a situation I’d have to report, but he’d already told me, so it would too late.  I asked him, “Did you read the informed consent?” (In which I’d listed the types of disclosure that mandated reporting). He said, “No, not really.” This taught me a lesson, and now I review every line of the informed consent form with a client at the very beginning. 

What did I do? I reported it, fully expecting that the client would then experience some negative consequences.  He already had a mentor because he was being monitored by his licensing board for chemical dependency.  So I called the mentor and told him, and the mentor reported it to Committee for Impaired Physicians. I then called the patient’s treating psychiatrist, who agreed that this should be reported to the medical licensing board. 

This report highlights several issues that may come up regarding disclosure. One is that clients may not realize the risks of certain disclosures, even if they have signed informed consent forms. The therapist needs to go over the forms with them to be sure they understand them.  Sometimes even if they fully understand the reporting laws, they may still disclose reportable material to the therapist.  A counselor who worked for the Post Office recalled,

A client may say, ‘I have something really heavy to tell you.”  I usually respond, “Wait -- Time out. Remember that paper you signed that listed the three things counselors can’t hold confidential. They are if there’s any criminal activity, or any child abuse, or if you’re a threat to yourself or others.”  Through the years I’ve had people say, “I don’t care. I want to tell you anyway.” For example, a client who’s a mail carrier told me he’d exposed himself. Not on the job, but of course I couldn’t be sure he’d be safe on the job and not expose himself there. So I told him, you have to tell Labor Relations. Either you do, or I will. So he told them. I think they fired him. It was quite a few years ago. 

Regarding this therapist’s comments to his client about the areas that the counselor can’t hold confidential, it’s important for the counselor to be specific about the kinds of criminal activities that must be reported. 

Another point that the story of the impaired physician demonstrates is that a lack of understanding of the significance of a client’s behavior may result in the client not experiencing the natural consequences of his behavior. As another therapist commented: 

Another therapist added:

When a client discloses behavior with another person with whom they are in a fiduciary position, and the therapist believes there is a significant risk of harming others, we believe it is the therapist’s ethical duty to describe the behavior to the professional association, licensing agency, or other appropriate body. 

c. Client discloses illegal behavior

There is, of course, overlap between the dilemmas involving illegal behaviors and those discussed in the sections above. Some illegal behaviors may have endangered or are likely to endanger others. In such cases, the legal and ethical concerns are congruent and reporting feels like the right thing to do.  Below is one counselor’s query:

In the course of giving his sexual history, my new client disclosed that he was going online for sex, and that his compulsion has progressed to where he’s now looking at child pornography, downloading it, and masturbating to the images.  He has children the same age as the images he’s downloading. He hasn’t had a hands-on crime, but it’s clear to me that his addiction is progressing. What do I do?

Although viewing child pornography online is not a crime, downloading it is a felony, subject to long imprisonment. This doesn’t mean, however, that the therapist is required to report this activity to the FBI.  The real issue here is whether there is a significant risk of danger to the client’s children or other children. In the above situation, the therapist decided that the risk to the children was real enough that she reported the client’s behavior.

In another scenario, a client discloses viewing child pornography online as well as downloading it.  He also views and downloads adult pornography. He spends hours per day on the computer, but has not had any real-life sex with anyone but his wife. 

This man, too, is committing a felony, as he’s downloading child pornography, but most sex addiction therapists would probably not report him. He would be counseled urgently on his legal risk and attempts would be made to motivate him as strongly as possible to maximize his treatment and recovery work. 

d. Client discloses acting out with another therapist.

A therapist (“A”) who works at an inpatient/outpatient sex addiction treatment center related:

Most therapists at the workshop agreed that doing nothing (other than continuing to work with the client) is not an option. Therapist B has behaved unethically, causing harm to the client. Future clients of therapist B are also at risk of being harmed. Therapist A’s professional relationship with B has been damaged.  The institution where both work is now at risk of being sued. Finally, various professional associations and licensing bodies mandate that their members report professional misconduct of a colleague or risk being liable themselves. These considerations override the client’s request of confidentiality. Clearly, something must be done.

Some suggested options for therapist A were:

• Encourage the client to report B to B’s licensing board or to a supervisor at the treatment facility.  [In this case, the client was asked but emphatically refused.]
• Have a talk with B to assess the credibility of the client’s information. 
• Discuss this information with other members of the client’s treatment team, and together decide what to do. [It is generally permissible to discuss client information with other members of the treatment team.]
• Report B’s behavior to A’s supervisor or the CEO or other person in charge of the facility.
• Report B’s behavior to B’s professional association or licensing body.

Some institutions have written guidelines governing situations such as this; those that don’t should. This is a predictable situation that should not be left to the individual therapist to handle. In the medical profession, when there is knowledge of a physician’s problem – such as chemical dependency or inappropriate behavior – some states have in place physician health associations to assist the professional in a manner that doesn’t involve reporting him to the licensing board. The errant physician is confronted by at least two colleagues and offered treatment.  Only if the physician refuses is he or she reported to the licensing board.  If therapist A does not want to risk B’s career without obtaining further information, it’s highly desirable that several therapists confront B, not A alone.  In fact, A may choose not to be involved at all. 

Resolution of the situation requires clarification of  therapist A’s goals. Do these include helping the client through the relapse? Getting therapist B to stop the behavior? Getting therapist B some help? Keeping other clients safe? Decreasing the institution’s legal exposure? This is why it’s critical for treatment agencies to have clear-cut, written ethical guidelines which include detailed information for therapists about how to handle this type of situation. 

Another situation included a probationer and a probation officer. A female probationer told the therapist that the probation officer made inappropriate advances to her. The therapist, who had known the probation officer for some time, was quite disturbed by this. The probationer had a history of lying, exaggeration, and making false allegations against other care providers. The therapist called the officer and told him of the allegations and stated that she was going to write up an incident report and turn it into his supervisor.  There was an investigation and the officer was removed from the case and another assignment was made.  A therapist must report all allegations of sexual abuse about a care provider when reported to that therapist whether or not the therapist believes them to be true.  Only those in higher authority can make that determination.

e. Another person wishes information disclosed by a client who is now deceased.

What happens to a client’s information if the client dies?  The American Psychiatric Association is clear about this. Its Ethics Primer (p. 43) states: 

This is, in essence, the legal position of the American Psychiatric Association, and perhaps of other counseling and psychology agencies.  Nonetheless, ethical dilemmas arise in which it may be in the best interests of another person for the counselor to reveal some information. The counselor must decide in each case what the ethical thing to do is.  A therapist reported,

A self-identified sex addict came to see me. I saw him for an initial session, and he gave me his sexual history. He was also depressed. I asked him to bring his wife in to the next session. The day before the next appointment, he committed suicide. A few weeks later the wife came to see me. She wanted therapy to deal with the suicide, and she had found his [sex addiction] Step One on his computer.  I treated her like any other co-sex addict. We read the disclosure together. I went through it with her and we talked about it. I helped her through the disclosure, explained what the sex addiction was. But what should I have done had the wife not found the husband’s first step? What if all she knew was that he was a sex addict? 

Had the wife been unaware that her husband was a sex addict, the therapist’s course of action would have been more difficult, as she would have had to decide whether to disclose this to the wife. The therapist’s ethical decision was made even easier by the wife’s discovery of the man’s First Step, so that the wife already had quite a bit of information before she consulted the therapist. The therapist’s job then became to help the wife process information she had already learned, in contrast to having to disclose to her. 

Another counselor’s experience:

A psychologist related,

Losing a spouse or child to suicide is devastating. The survivors usually spend years trying to understand what happened and assessing (all too often unrealistically!) what they did wrong and how they could have prevented it.  Knowing that a therapist possesses information about the suicide but will not disclose it can keep the survivors from experiencing closure for many years. 

Leaving aside the legal issues, if you decide that ethically you are going to disclose some information to the survivor, you need to realize that what you say may stay in that person’s brain for many years. Will the survivor be better off receiving upsetting information about which he or she can do nothing? What you tell should depend on what the therapist’s ongoing relationship is going to be with the survivor, and what they want to do with the information. Ideally the survivor will become a client with whom you will have an opportunity to process the information at length, and the outcome will be increased peace of mind for the survivor. 

Regarding the first case in this section --the surviving spouse of a sex addict who killed himself -- his therapist gave this follow-up:

Another counselor opined:

II. Information originating with a third party (another client, another therapist, law enforcement, 12-step program)

 Occasionally information may come to the therapist from outside sources, with a resultant dilemma about what to do with the information. For example, your client, Steve, reports that at a meeting of Sex Addicts Anonymous (SAA), Joe, who also happens to be your client, disclosed he was continuing to have an affair. Until now, you were not aware of Joe’s relapse. 

There are several issues here. First of all, Steve should not have reported this to you, and the question is why he did. Steve is well aware of the 12-step slogan, “What you learn here stays here.” Steve’s motivation needs to be discussed with him in therapy.   

As for the relationship with Joe, you cannot break Steve’s confidentially and directly confront Joe. One of the authors (BL) describes her approach in this situation:

The ethical challenge here for the therapist is to make use of the information without breaking the other client’s confidentiality.

Polygraph

Whenever a therapist obtains information from outside sources suggesting that the client is lying, the question arises of how to handle this information. The dilemma is typically that described above – how to use the information without violating some else’s confidentiality. Therapists who treat mandated sex offenders have another tool at their disposal – the polygraph, which is often a part of the treatment contract for sex offenders. For non-offenders, simple mention of a polygraph can be informative.  In the pain medicine and addiction medicine practice of one of the authors (JPS), if I have concerns that a patient who is taking prescribed pain medications is concealing illicit drug use, I sometimes say, “I’m thinking of having you obtain a urine drug screen today. If I do, am I likely to find anything in it other than what I’ve prescribed?” At that point, the patient who’s been using illegal drugs is likely to admit it, whereas the patient who’s “clean” will not have a problem with the request.   Most of the time, I don’t end up ordering the test. Similarly, the therapist who strongly suspects a client is continuing to lie may ask, “Would you be willing to take a polygraph test?”  Those who have nothing to hide are more likely to assent. 

A counselor reported,

III. Information originating with the therapist 

Years ago when the reigning paradigm for psychological treatment was psychoanalysis, the therapist was ideally a blank slate who revealed nothing about himself to the client. Modern therapists are less rigid about occasional self-disclosure when doing so is in the interest of the client and will further the therapy.  Counselors who themselves are in recovery from addiction will often disclose this in a general way, as it may increase the comfort level and the trust of the client.  Some professionals may have no choice about this – for example if they have written books or articles in which they talked about their own addiction recovery. Especially with sex addiction, however, it’s a good idea to avoid giving details of your own sexual acting-out history. Clients are also likely to ask how you got into the type of professional work you do, and this too may involve therapist disclosure about addictions.

Here’s what some seasoned counselors said about self-disclosure:

Counselor 1: 

Counselor 2: 

Counselor 3: 

We believe that therapists working with sex offenders should avoid disclosing anything personal about them. Many offenders are manipulative, if not psychopathic.  Therapists may want to believe they are in a relationship with the offender; however, only the therapist may be in the relationship. Offenders may use any information about the therapist to their own advantage. One must be extremely cautious when doing any disclosure with a sex offender. 

Treatment with an offender is very different than with other patients. Gerald Blanchard’s book, The Difficult Connection, (1995)) is an excellent resource in this regard. Although he writes about establishing a relationship, the relationship is one of respect for the individual and not about disclosing any information. Any personal information about the therapist is unnecessary. One of the authors (BL), explains:

We believe it’s important for the therapist to have appropriate boundaries. After that, each therapist needs to decide for themselves what they feel comfortable with. One of the authors (BL), who works with sex offenders, continued:

I have very strict boundaries and hardly disclose anything about myself. Since I was trained in Ericksonian techniques, I’ll sometimes tell stories to make a point. For example, when talking about shame, I’ll tell a story about how my parakeet died when I was 11. I let it out of the cage after my mother told me not to, and it broke its little head. I took the dead parakeet and put it back on its perch, leaning against the cage, and then my mother came home and said, “What happened to the parakeet?” and I said, “I don’t know.” But then because I was so full of shame I had to tell her what happened.  And she was very nice, and we buried the parakeet together. So that’s my story about shame. I’ll tell that kind of information about myself, but not personal information.  When my patients ask me if I’m in recovery, I say, “Yes, from life, so everyday is a meeting for me.” 

Another counselor related:

A psychologist self-discloses any information very judiciously. He said:

A therapist described how she has changed from the early days, when she followed the analytic “blank screen” school in which she was trained:

The work calls upon us to be more real – we have to be wiling to bring down our walls, personas, and reveal ourselves (as appropriate, and with Professional boundaries, etc.) in ways traditional therapies may not.

Bill Herring, the co-leader of the ethics workshop held at the NCSAC conference in 2003, has given much thought to the complexities of therapist self-disclosure: 

As Herring points out, the reality is that therapists, like other employed people, do inevitably get some needs met through their work. At the same time because so much of the therapist’s work is based on his relationship with the client, the therapist must be very conscious of the impact of his actions, including self-disclosure of one form or another, on the patient. We must constantly ask ourselves whether we are doing it for the client or for ourselves. Many therapists have had patients tell them that one of the reasons they didn’t stay with their last therapist was that they always seemed to talk about themselves. Some of that may be the patients’ distortion. However when therapists describe disclosures they have made to their clients, sometimes it appears that boundaries may have been crossed.  

One of the authors (BL) related:

Ideally,  therapists do not disclose their personal baggage but, if in deed  this happens in the course of therapy and countertransferance,  then the therapist must be authentic and reveal themselves and take responsibility. This can be done if the therapist is always listening to themselves and exploring their own feelings.  It is in this type of genuine care that therapists can make their greatest contribution.

A physician added:

According to Marnie Ferree, a sex addiction therapist:

A somewhat different perspective was presented by clinical social worker Roy Berman:

When considering self-disclosure, it’s important for the therapist to ask themselves each time about the purpose of revealing the information.  It needs to be for the benefit of the client and not the therapist. It can be helpful to address the client’s motivation. As one therapist reported: 

Clients sometimes complain that the therapist spent too much time talking about themselves. Also consider that any information you disclose about yourself may be used in various ways by the client – including, if the relationship sours – to try to discredit you. So be discreet. A therapist at a treatment center related:

Richard Blankenship, M.Ed., M.A., focused on issues of the professional consequences of self-disclosure:

An addiction-trained therapist who was employed by the post office related that over the years he’d had opportunity to speak with many employees, to learn what therapy models had worked for them and what spoke to them overall during their therapy: “The number one answer I heard all the time was ‘what really helped me was that my therapist seemed real’.” For addiction treatment, being real means some self-disclosure about the addiction. An experienced sex addiction therapist who does disclose that he’s a recovering sex addict added:

As other therapists have reiterated, the goal of self-disclosure needs always to be to help the client. Self-disclosure can make the therapist seem more real to the client and may increase the client’s trust. The client may think,  “She’s been through the same thing, so she can really understand me.” It can model a willingness on the therapist’s part to be honest. But there are times when it would be better for the client to have the therapist not reveal early on about some issue, or indeed not disclose at all.  One example might be the therapist with a history of sexual abuse who is treating a sex offender; knowing of the therapist’s prior victimization might make the offender hold back some feelings or facts out of fear of being judged by the therapist. It might be wise for the therapist to withhold such revelations until late in the therapeutic relationship, if at all.

Sexual orientation

Disclosure of the therapist’s sexual orientation is another issue that comes up often enough in sex addiction treatment.  How counselors respond depends on their own comfort level, on whether or not they have a high public profile in the community as a gay or lesbian therapist, and their concern about appropriate boundaries. One gay therapist doesn’t volunteer the information but it’s clear to most people that he is gay. If asked directly, he says he’s gay.  A gay therapist explained:

What about therapists going to the same 12-step's meeting as their clients?

Most therapists who are themselves recovering from sex addiction use the Twelve Steps in their recovery, and many continue to attend 12-step meetings. Such therapists routinely recommend 12-step meeting attendance to their recovering clients. Unless they live in one of the major cities in the U.S., most sex addicts do not have a wide choice of “S” meetings to attend. How do recovering therapists feel about attending the same meetings as their clients?  We posed this question to sex addiction professionals on an e-mail discussion group. Twelve experienced clinicians responded: ten said no, and two said maybe or it depends. Because this is such an important and recurrent issue, we have quoted some of the respondents. Here are several responses from the first group:

Two respondents gave less definitive replies.

The consensus of experienced therapists is clear: For a therapist and client to attend the same meeting is likely to complicate the therapeutic relationship. It is virtually impossible to prevent blurred boundaries and information learned by both parties at the meeting from affecting into their professional relationship. Even more problematic, the presence of both at the meeting is likely to inhibit one or both from sharing current struggles and asking for help. Even the minority of therapists who believe it’s occasionally okay to attend the same meetings recognize that they are not likely to get real help during those meetings. The professional will be reluctant to share his challenges; a relapse would be an even bigger problem and might risk his own recovery.  And if the meeting contains several clients, there’s always the temptation of becoming the guru in the meeting.

If separate meetings are not available, consider starting a professionals’ meeting, find a meeting in another town, or attend a 12-step group that focuses on recovery from your other addiction, if you have one. Strengthen your relationship with your sponsor. Find on-line meetings. One therapist related that in lieu of attending local meetings, “I joined the NCSAC [now SASH] Board of Directors and found the company of other professionals, some of whom were in recovery, all of whom understood this addiction, a wonderful substitute.”

Sponsorship

Clients who learn that their therapist is also in 12-step recovery from sex addiction may ask their therapist to be their 12-step sponsor.  We believe this to be a bad idea.  The role of a sponsor differs from that of the therapist, and it is best to keep them separate. 

Sponsorship and therapy have very different roles. The sponsor guides the person through the steps and is not the therapist. The therapist’s role is to not only help the person with his or her sex addiction, but to confront if necessary and explore deeper issues. The sponsor is often an advocate for the patient and if transference happens with the therapist who is also acting as the sponsor, than recovery may be dropped entirely.  The sponsor may often share their own faith, hope and experience;  it may appropriate for therapists to share their own experiences about their recovery, but inappropriate to share about current struggles. Very often the patient needs to develop a support group and the sponsor is often instrumental in helping the addict do this.  If the therapist is also the sponsor, the therapist runs the risk of having the patient enter into their own support system and therefore increase the risk of further boundary violations.

Conclusion

The purpose of this article was not to give definitive answers to every ethical dilemma that may arise, but to offer some suggestions and avenues for further discussions. The ethical choices we all have to make in our work sometimes come with ease but more often with much thought and consideration. The decisions we make today can affect our patients’ lives and our own for years to come. We owe it to our profession and to the others who come after to set precedent and make the difficult choices. We must never take our responsibilities lightly or glibly. Seeking out consultation and the ability to ask for help are essential to this endeavor.  

Each day can bring new quandaries, and the way in which we deal with what is given to us builds our strength, hope and courage. We often have to make decisions that are difficult and can leave us feeling alone and questioning ourselves.  The day we think we have all the answers is the day we fail ourselves and our patients. We must always strive to do the Next Right Thing.  If our decisions do not always yield the results we thought they would, hopefully we can move on and learn from our mistakes.  It is not a shame to fail, but it is, not to try.

References

1. Alcoholics Anonymous World Services, (1953). Alcoholics Anonymous. New York: author.
2. American Bar Association Center for Professional Responsibility (1998) Model rules of professional conduct. Chicago, IL: American Bar Association.
3. American College of Physicians (1998). Ethics manual: Fourth edition. Annals of Internal Medicine, 128, 576-594.
4. American Medical Association Council on Judicial Affairs (2000) Code of medical Ethics: Current opinions.  Chicago, IL: American Medical Association.
5. American Psychological Association (2002). Ethical Principles of Psychologists and Code Of Conduct. American Psychologist, 12/02.
6. American Psychiaric Association (2001). Ethics Primer. 
7. Bissell, L. & Royce, J. (1994) Ethics for addiction professionals.  Center City, MN: Hazelden.
8. Blanchard, G (1995). The Difficult Connection: The therapeutic relationship in sex offender treatment. Brandon, VT: Safer Society Press.
9. Burkemper, E. M. (2002) Family therapists’ ethical decision-making processes in two duty-to-warn situations. Journal of Marital and Family Therapy, 28, 203-211.
10. Chaimowitz G. & Glancy, G. (2002). The duty to Protect. Canadian Psychiatric Association. Accessed on http://www.cpa-apc.org/Publications, 12/9/04
11. Coale, H. (1998). The vulnerable therapists: Practicing psychotherapy in an age of anxiety.  New York: Haworth.
12. Corey, G., Corey, M. ,& Callanan, P. (1998). Issues and ethics in the helping professions.  Pacific Grove, CA: Brooks/Cole
13. Corley, M.D., & Schneider, J. P. (2002a). Disclosing secrets: Guidelines for therapists working with sex addicts and co-addicts. Sexual Addiction & Compulsivity, 9, 43-67.
14. Corley, M.D., & Schneider, J.P. (2002b) Disclosing secrets: When, to whom, and how much to reveal. Wickenburg, AZ: Gentle Path.
15. Gallagher, T.H., Waterman, A.D., Ebers, A. G., Fraser, V. J., & Levinson, W. (2003). Patients’ and physicians’ attitudes regarding the disclosure of medical errors. Journal of the American Medical Association 289, 1001-1007.
16. Herring, B. (2001). Ethical guidelines in the treatment of compulsive sexual behavior. Sexual Addiction & Compulsivity, 8, 13-22.
17. Hunter, M. and Struve, J. (1998). The ethical use of touch in psychotherapy. Thousand Oaks, CA: Sage.
18. Irons, R.R. and Schneider, J.P. (1999). The wounded healer: Addiction-sensitive approach to the sexually exploitative professional. Northvale, NJ: Jason Aronson.
19. Mazor, K.M., Simon, S. R., & Gurwitz, J. H. (2004) Communicating with patients about medical errors: A review of the literature. Archives of Internal Medicine, 164, 1690-1697.
20. National Board of Certified Counselors (2002). Code of ethics, , p. 9, www.nbcc.org/depts/ethicsmain.htm   accessed on Nov 15, 2004
21. Pinching, A.J., Higgs, R., & Boyd, K. M. The impact of AIDS on medical ethics. (2000). Journal of Medical Ethics. 26, 3-8.
22. Rave, E.J. and Larsen, C. C. (Eds) (1995). Ethical decision making in therapy: Feminist perspectives. New York, NY: Guilford Press
23. Schneider, J.P., Irons, R. R., & Corley, M.D. (1999). Disclosure of extramarital sexual activities by sexually exploitative professionals and other persons with addictive or compulsive sexual disorders. Journal of Sex Education and Therapy, 24, 277-287.
24. Schneider, J.P., Corley, M.D., and Irons, R. R., (1998).  Surviving disclosure of infidelity: Results of an international survey of 164 recovering sex addicts and partners. Sexual Addiction & Compulsivity, 5, 189-217.
25. Schneider, J.P. and Schneider, B.H. (2004). Sex, Lies, and Forgiveness: Couples Speak on Healing from Sex Addiction, 3rd Edition. Tucson, AZ: Recovery Resources Press.
26. Stein, M.D., Freedberg, K. A., Sullivan, L.Ml., Savetsky, J., Levenson, S. M., Hingson, R., & Samet, J. H. (1998). Sexual ethics: Disclosure of HIV-positive status to partners. Archives of Internal Medicine, 158, 253-257.
27. Tarasoff v. Regents of the University of California, 17 Cal.3d 425,551 P.2d 334 (1976).