Insights: When Clients Develop Romantic Feelings For Therapists – Ana Rabasco
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Have you ever been in a situation where your client develops romantic or sexual feelings for you? What’s the best way to respond? The therapy relationship is an essential factor in treatment outcomes, so how can we best protect it in these scenarios?
We sat down with Ana Rabasco, Postdoctoral Fellow at Brown University and author of ‘Well. That Was Awkward: When Clients Develop Romantic Feelings For Therapists’. Ana Rabasco, Amy Mariaskin, Dean McKay. (2023). Cognitive and Behavioral Practice, 30.
This paper looks at how we can use CBT principles to provide explanations for why client attraction happens and offers guidelines for how to best handle this issue from a CBT perspective. In this article, Ana outlines practical suggestions to take forward into your practice.
Shining a light on client attraction to therapists
For readers that aren’t familiar with the paper, could you give us a 2-minute summary in your own words?
It’s a conceptual paper about client or patient attraction to therapists, written from a cognitive-behavioral perspective. Although this topic has been covered quite a bit in psychodynamic and psychoanalytic literature, there’s a gap in relation to cognitive-behavioral therapy (CBT). In this paper, we talk a lot about how to conceptualize client attraction from a CBT framework when it happens in the therapeutic context. We then move into talking about how to handle this issue from a CBT perspective (because that could look quite different to a psychodynamic perspective), and the different skills and practices that might come into play. We end with case illustrations, which hopefully help to bring a lot of this together. The cases range from casual disclosures to more serious ones, in which we discuss the causes of the attraction, the events leading up to it, how the therapist handles it, and how the situation pans out.
Why should practitioners care about this paper?
Because client attraction happens a lot in the therapeutic context! Previous research shows that it’s quite frequent: in 2014, Sonne & Jochai found that the majority of therapists have had at least one client disclose romantic or sexual attraction to them. In CBT and third-wave therapies like DBT and ACT, we don’t talk about it much at all in either training or supervision. Client attraction could directly affect therapists or the people they supervise and significantly impact the therapy relationship, but if we don’t talk about it, how can we best know how to handle it?
What made you decide to explore this topic?
It really came from my own clinical experience. I had a very challenging experience with a client while I was still in grad school, where they expressed romantic attraction to me. I remember, in that moment, how unprepared I felt I was. We’d never covered this in any of my courses on intervention, in therapeutic practice, or in supervision. I was grateful that I had great supervisors, but we hadn’t really talked about this before. When I went to search the literature to find out more, I felt like it wasn’t out there and was surprised by how few papers there were on this topic, especially from a CBT lens. As I was going through this situation, it felt like there was an ‘underground’ sharing of stories and clinical experiences with supervisors, but it wasn’t really talked or written about formally anywhere.
I felt motivated to do something. I wanted things to be different for people moving forward because I knew that many people would face this, especially since it can often come up when people are younger and earlier in their careers, and they are less experienced. As I move forward in my career, I want to provide that mentorship for new clinicians as well. Psychodynamic and psychoanalytic literature covers this a lot, but nobody is talking about this in CBT and third wave therapies. I was keen to move in this direction and try to fill a little bit of this gap in the literature.
Given that this appears to be a common scenario, clinicians feel unsure about how to respond, and the therapeutic relationship is such a significant factor in treatment outcome, why do you think this topic is not covered in training?
I don’t know for sure, but I think it has a little bit to do with CBT trying to differentiate itself from psychodynamic practice. With psychodynamic psychology being so focused on interaction, and talking so frequently about transference, countertransference, and eroticized transference, I wonder if there was historically a desire for CBT to move in a different direction, to give it its own clear space.
In the process of that, this sort of experience might have been neglected, even though it does still come up. Over time, it wasn’t really emphasized, so it wasn’t incorporated into training. However, I think that this issue can be very uncomfortable to begin talking about and handle in the moment, especially if it’s not something that’s discussed or covered in your training.
‘If we don’t talk about it, how can we best know how to handle it?’
What is the most interesting or significant part of the paper for you?
What felt most significant during the process of writing the paper was thinking through how I would respond to these situations using the CBT framework, and how CBT principles can be used to help explain and understand a client’s behaviors, as well as guide how to respond to them. One of our co-authors, Dr. Mariaskin, is a full-time clinician and she had a really helpful perspective on how to approach these cases as we went through them. We were able to focus on the specifics of these cases, such as the actual words that a clinician could use, or what should be emphasized and kept in mind.
When these situations arise, it’s worth keeping in mind that CBT principles can inform both your own and your client’s understanding of what’s going on. As such, we can use the CBT or third wave skills ourselves when dealing with client attraction, but we can also use the CBT framework to conceptualize the case collaboratively with the client, and use functional analysis to understand the reasons why the attraction has arisen and work out the best way to respond.
The other really useful insight from this paper lies in how client attraction can be turned into a source of progress. If the client can engage in a collaborative case conceptualization of where this attraction is coming from (such as social isolation or difficulties in their current relationship), they can use it as a springboard to set treatment goals. Their attraction might invite them to consider what’s important to them moving forward, and what they might like to work on. Perhaps they’d benefit from social skills training, values work, or setting behavioral goals around dating or communication with their partner. This is the kind of practical clinical information that could really help therapists who are dealing with this situation.
Clinical takeaways for professionals
How can we help clinicians prepare for and respond to situations of therapist attraction most constructively?
One of the aims of your paper was to start conceptualizing a CBT model that can address how therapists approach client attraction to therapists. With that in mind, what are the key clinical implications that practitioners should take forward into their practice?
- Set up the therapeutic environment. From the outset, clinicians should try to have a clear setup of the therapeutic context or relationship with their client. This means being very clear about boundaries, and maybe having different clinical policies in place. This advice comes from the preventative angle, and so I would recommend having a really clear policy on when you communicate with clients and what means of communication you use. I would advise being very deliberate about these clear parameters from the start of your first session. It’s also a good idea to openly acknowledge that the therapeutic relationship can feel emotionally intimate. Explain that it can result in intense emotions and attachments and invite the client to share these feelings if or as they arise.
- Re-orient yourself to your therapy environment. We know from previous research that therapists often feel unprepared for client attraction to occur, so it is worth reminding yourself that it is possible. We need to normalize the likelihood of attraction happening in training and supervision generally so that we are better prepared to respond, if and when it occurs.
- Emotion identification. Try not to discount your own sense of what might be going on. In cases with more subtle signs of attraction or before it has been disclosed to you, I know from my own experience that you can almost talk yourself out of it or hope that it’s not happening. However, this is avoidance, and in CBT we know that avoidance doesn’t always work very well. I would advise acknowledging and paying close attention to your own feelings and behaviors during sessions, such as whether you feel uneasy or act differently to avoid certain things. Keep monitoring the therapy relationship – these early signals can give you the opportunity to explore what your uneasiness may be communicating about the client and the therapeutic relationship, whether in supervision or with colleagues. It can give you the chance to plan potential responses and respond in a considered way rather than feeling blindsided.
- Exposure and assertiveness. We need to learn to trust our clinical instincts, even if the signs are more subtle, and lean into the self-exposure of using assertiveness skills to bring the subject up with the client (if it feels beneficial), or consulting with other clinicians (or a supervisor, if you have one). We should be talking about it earlier on, rather than letting the issue simmer under the surface, where it could end up exploding or going off the rails. Modeling assertiveness and addressing client attraction in session can feel uncomfortable, which is why exposure and role playing these types of situations and scenarios during training or supervision can be helpful, before a real-life situation has occurred.
- Use the case formulation. I’d suggest drawing on the case conceptualization to understand the unique reason for and function of the client’s attraction, and using this as a guide to establish the best response. Use it collaboratively to help explain where the behavior is coming from, both for the therapist and the client.
- Normalize and reframe. When addressing a situation with a client, it can be helpful to remind them that developing feelings of attraction towards their therapist is not unusual, and can be used to positively reframe the situation and learn more about the client. For example, the feelings can be used to give you information about useful treatment goals and direction for skills development.
What might the main challenges be for therapists who want to start incorporating your recommendations into their clinical practice?
A significant barrier is going to be discomfort about being in this type of situation, or doubt about how to best navigate it, which comes from not having a lot of training or research in this area. Another big one is the idea that it might not happen to you, because we are not generally aware of how common it really is.
How can we reduce potential discomfort around discussing these types of situations in supervision?
Maybe we just need to accept that it’s uncomfortable, but we have to do it anyway. I think that’s where we can use CBT skills in our own lives and in our own practice. We can practice distress tolerance skills, such breathing exercises and muscle relaxation, as we need them.
We can also reduce potential discomfort by both leaning into it and exposing ourselves, as well as (from a bigger systems perspective) incorporating it more into graduate training and the supervision role.
What other recommendations do you have for any supervisors/clinical team leads who might be reading this?
From a supervision perspective, we can make some changes so that the next generation of clinicians have more space to talk about this issue and develop the skills to help them deal with these situations more confidently.
As a supervisor, I’d suggest bringing up early on the idea that this can happen, even if it’s just a brief mention. It’s important to educate students so they can recognize if client attraction starts to happen in their clinical relationship. If they’re noticing some subtle signs, they should feel encouraged to bring them up.
As a trainee, I found it very helpful when supervisors mentioned their own experiences. I think that, if supervisors feel like it’s appropriate, it helps to normalize the issue, normalize the frequency that it takes place, and takes away some of the self-blame. It would be useful to hear how the situation was handled, or what could have been done differently. If a supervisor handled it super well, I would want to emulate that.
Looking ahead
What’s the next step for you and this research?
We have a follow up project. It’s a mixed methods study, so it’s qualitative and quantitative. We have surveyed a couple of hundred clinicians and trainees about their experiences with client attraction in the therapeutic context, and we are now at the point of analyzing the qualitative data and asking people about their experiences. Has this happened to you? What happened? How did you handle it? What type of supervision did you get?
I’m super excited about this project because we’ll have data about how many clinicians have experienced client attraction in the therapeutic context, and what it looked like.
What is your hope for this paper? If you fast forward 5 years, what would you like it to have achieved?
I hope that this paper is just the starting point for talking more about this topic. Ideally, CBT-oriented training programs will devote more space to this topic and supervisors will change a few things in their supervision. By doing this, I hope we can plant the seed that this is something that happens. It’s not the clinician’s fault or the client’s fault; it’s just something that can occur, and there are ways to navigate it helpfully.
I also hope that we can continue getting empirical data with the research in this area and trying to bridge the gap between clinical work and research. This is an interesting topic to do that with, so I hope that once our new paper or project is out, a few papers might come from it, and that it might continue to be built upon by other folks.
As we talk more about this, I hope that client attraction doesn’t have to be a situation that is always really negative. Especially if we’re more aware, we could turn this into a more positive clinical experience and use it to inform collaborative goal setting and conceptualization. This isn’t going to happen in every case, but with a little bit more training and discussion, I hope we can move towards this possibility.
References:
Rabasco, A., Mariaskin, A., McKay, D. (2023). Well. That Was Awkward: When Clients Develop Romantic Feelings For Therapists. Cognitive and Behavioral Practice, 30.
Further Reading:
Jacob, C. J., Byrd, R., Donald, E. J., Milner, R. J., & Flowers, T. (2022). Avoiding boundary violations: Recommendations for managing attraction to and from clients in response to the Healthcare Providers Service Organization’s 2019 report. Journal of Mental Health Counseling, 44(1), 6-17.
Vesentini, L., Van Puyenbroeck, H., Van Overmeire, R., Matthys, F., De Wachter, D., & Bilsen, J. (2023, 2023/08/01). How therapists experience and manage patients’ romantic and sexual feelings for them. Academic Psychiatry, 47(4), 352-359. https://doi.org/10.1007/s40596-022-01714-0