This paper analyses social, ethical and legal issues within a complaint initiated by the NSW Health Care Complaints Commission (HCCC) against a psychologist, Steven Kreft (HCCC v Kreft, 2011). The HCCC investigated a complaint by a client of Kreft of personal and sexual disclosures, as well as unprofessional treatment in the solicitation of a photograph of the client in which the client was dressed in underwear. Kreft’s actions are assessed in light of professional and ethical standards as well as potential breaches of the law. Steven Kreft, was an experienced psychologist narrowly specialising in the treatment of men with anxiety conditions using cognitive-behavioural therapy (HCCC v Kreft, 2011). The client, a 19-year-old married woman, was referred to Kreft because of anxiety and possibly panic attacks, but during the initial stages of counselling, she raised relationship problems, her appearance and sexual needs and practices with him and these became the focus of their sessions.
Kreft conveyed to the client that he was not experienced or skilled in the treatment of relationship problems or sexual disorders, however, the client stated that she wished to continue working with him and he did not insist on referring her elsewhere. The client ultimately accused Kreft of failing to observe proper professional boundaries and engaging in inappropriate discussions of a personal nature in which he: Complimented her on her appearance referring to her petite size, short height and thin build, and likened her to his girlfriend; Commented on her wearing Bonds underwear like his girlfriend wore; Asked the client to comment on his physical appearance;
Disclosed details of his personal life including the number of sexual partners he had had, that his girlfriend would share a bed with other girlfriends when they slept over, that he had been in love numerous times, and that he had thought about homosexuality during his youth (HCCC v Kreft, 2011). In addition, Kreft was accused of failing to follow or observe appropriate therapeutic practice and/or failing to observe proper professional boundaries when he asked the client for photographs for a study in which other people would rate the client’s appearance. One of these photographs pictured the client dressed in underwear. Kreft copied these photographs onto his own computer for later presentation to unnamed others.
This exercise was not recorded in the client’s clinical notes (HCCC v Kreft, 2011). The HCCC investigated the client’s complaints and took disciplinary action against him. There are numerous social, ethical and legal issues in this case. Although Kreft was in fact a psychologist, for the purpose of this paper, his conduct will be assessed against the Australian Counselling Association’s Code of Ethics and Practice (2012). This paper will explore the power imbalance between Kreft and his client, the effect of his behaviour on the therapeutic relationship and whether Kreft’s behaviour might have breached sexual harassment laws. Ethical and legal guidelines exist to offer protection to people who may experience harm as a result of the actions of another person. According to Welfel (2013, p.3), professional ethics in counselling encompasses five dimensions of behaviour including having sufficient knowledge, skill and judgement; respecting the client’s human dignity and freedom; using a counsellor’s inherent power responsibly; and, acting to promote public confidence in the counselling profession.
This provides a useful framework for assessing Kreft’s conduct in this case. Beginning with Kreft’s expertise, Kreft usually used a strict cognitive-behavioural protocol for the management of anxiety and panic disorders. Kreft is described by his own treating psychiatrist as a skilled practitioner in a narrow field, having been trained to think rationally and logically. Kreft’s practice “involved administering protocols, carrying out logic-based interventions and requires his patients to occupy a mindset where they share a common objective and commitment to the treatment and its proposed outcome” (HCCC v Kreft, 2011 at 227).
Although referred to Kreft because of his relevant expertise, the treatment interaction became sexualised when the client began talking about her sexual experiences and practices. There was further exploration of her concerns about her personal appearance, low self-esteem, need for validation by men via her sexual activities and descriptions of her specific sexual behaviour. Here, Kreft was out of his professional depth. Specifically on this matter, the Australian Counselling Association’s (ACA) Code of Ethics and Practice states that counsellors must “endeavour to make suitable referral where competent service cannot be provided” (p.3) and “undertake regular supervision and debriefing to develop skills, monitor performance and sustain professional accountability” (p.3).
Although Kreft recognised that the client’s relationship and sexual issues were beyond his expertise and conveyed as much to the client, he could have insisted on referral, despite the client’s preference for continued sessions with him. The ACA further states that competence includes being able to recognise when it is appropriate to refer a client elsewhere (p.12). The rationale for this professional expectation is that counsellors are required to “take all reasonable steps to ensure that the client does not suffer physical, emotional or psychological harm during counselling sessions ”(p.4). Sexualisation of the therapeutic relationship can be harmful to clients, and in this case, it is difficult to see how it served the client. According to the ACA Code of Ethics and Practice, “the helping relationship constitutes the effective and appropriate use of helper’s skills that are for the benefit and safety of the client in his or her circumstances” (2012, p.3), and “counsellors must take all reasonable steps to ensure that the client does not suffer physical, emotional or psychological harm during counselling sessions” (2012, p.4).
In relation to the disclosures, for whose benefit where they? It is unclear what led Kreft to make sexualised self-disclosures and what purpose he thought they served. Perhaps it was a response to the client’s exploration of her relationships and sexual activities. Such client self-disclosure can sexualise the therapeutic relationship (Gurtheil & Brodsky, 2011, p. 183). Counsellor disclosures are inevitable and sometimes useful, but self-disclosure can become burdensome to the client and therefore detrimental. Gurtheil and Brodsky (2011) state that in cases of sexual misconduct, “a key turning point often occurs when the relationship shifts from a therapeutic exchange to one of sharing personal confidences and feelings” (p.114). They further state that even therapists whose practice deliberately includes open self-disclosure, it is rarely useful and usually burdensome for clients to hear details of the therapist’s emotional, sexual, personal or family life. “Such disclosures, especially when they involve sexual feelings, are nearly always considered boundary violations” (p.115).
It seems that Kreft may have been meeting some personal need by making the disclosures. Without having observed the interaction, it is difficult to judge, however, perhaps in an attempt to normalise the client’s experience or keep her engaged, Kreft seems to also be almost boasting of his own sexual prowess. This amounts to an exploitation of the client for his own needs. The APA states that, “counsellors must not exploit their clients financially, sexually, emotionally or in any other way (pp.4-5). If poorly handled, the power imbalance inherent in the therapeutic relationship can lead to exploitation of clients (Barnett, Lazarus, Vasquez, Moorehead-Slaughter & Johnson, 2007, p.402). A young female client, is less likely to challenge the appropriateness of such comments. In addition to the sexualised disclosures, Kreft devised an exercise based on his narrow focus on CBT, which he believed would help the client. He requested and obtained a photo of his client wearing a bra and underpants for the purpose of an exercise aimed at ‘challenging’ the client’s maladaptive or negative beliefs about her appearance.
The photo was to be shown to a number of unnamed people in order for them to rate her appearance. Kreft claimed in his testimony that he created the exercise based on his expertise and training. He did not state that he researched current effective practice or discussed the client’s needs in supervision. It would seem prudent to educate oneself about an unfamiliar field of practice or client. In fact, the ACA’s ethical expectations include counsellors committing to ongoing personal and professional development, as well as undertake regular supervision and debriefing (p.3). A cursory investigation of recognised treatments for body image problems Butters and Cash (1987) research into effective cognitive-behavioural treatment of women with body-image dissatisfaction found that a combination of methods produced improved affective body image, reduced maladaptive body-image cognitions and enhanced social self-esteem about fitness and sexuality. The methods included providing clients with information about body-image dissatisfaction, having clients construct a personalised hierarchy of body areas, desensitisation to automatic thoughts and developing counterarguments for irrational thoughts.
Butters and Cash (1987) did use observer ratings of client physical attractiveness as part of the series of exercises, but there is no suggestion that clients were to be barely dressed in the photographs used. Kreft seemed to exercise poor judgment in his selection of a photograph in which the client was so scantily clothed. Kreft seemed unaware of his power in the relationship. Power within the therapeutic relationship can take numerous forms. Proctor (2002, p.8) states that one basic form is societal power which is expressed in the imbalances between the genders and between the old and young. In this case, Kreft was an older male with a teenage female client. According to testimony in his case, Kreft was accustomed to working with male clients, so he may have been unaccustomed to working with a young female. He may have been unaware of the subconscious power he held in the relationship simply by virtue of his stronger position in society. Pope and Vasquez (2007, pp41-42) describe other forms of power that therapists have in relation to clients. These include the power of expectation–clients expects that the therapist’s interventions will be able to induce beneficial change.
Related to this is the power to choose the approach to therapy. Kreft chose to make personal disclosures and chose the therapeutic exercise involving the client’s photograph. She complied with the activity, although she stated in her complaint that she was very uncomfortable about it. Kreft failed to recognise this in her delayed provision of the photo, but also failed to recognise that any young woman might be uncomfortable with such an exercise, yet reluctant to refuse. He did not make this psychologically safe for her. Under the Victorian Equal Opportunity Act 2010, both the disclosures and the request for photographs could be deemed sexual harassment and therefore unlawful. A person sexually harasses another person if he or she engages in unwelcome conduct of a sexual nature in relation to another person in circumstances in which a reasonable person, having regard to all the circumstances, would have anticipated that the other person would be offended, humiliated or intimidated. Conduct of a sexual nature includes making orally, any remark or statement with sexual connotations to a person or about a person in his or her presence, and, making any comment of a sexual nature in a person’s presence (Victorian Equal Opportunity and Human Rights Commission, 2013a, p.79).
There are therefore three characteristics of behaviour that would have it constitute sexual harassment – being unwelcome; being conduct of a sexual nature; and being conduct that a reasonable person would consider likely to offend, humiliate or intimidate in the circumstances. There seems little doubt that Kreft’s disclosures about his sexual activities fit this definition of conduct of a sexual nature. In relation to whether the comments were unwelcome to the client, it certainly appears so, as she has complained of as much. For conduct to be unwelcome, it must be unsolicited or uninvited by the client, and regarded as undesirable or offensive by the client. Kreft does not suggest that the client invited the comments. Even if a client does not speak up or complain at the time, the conduct might still be considered unwelcome (Victorian Equal Opportunity and Human Rights Commission, 2013b, p.6).
The client’s age is a factor recognised as causing someone to tolerate behaviour even if unwelcome. Numerous sexual harassment cases have recognised how a power imbalance between the parties can contribute to a person remaining silent about how unwelcome the behaviour is (VEOHRC, 2013a, p.85). The final element in sexual harassment is whether the conduct occurred in circumstances in which it could reasonably have been expected that the conduct would offend, humiliate or intimidate the person. Again, given the client’s age in relation to Kreft, and the highly sexual nature of the disclosures, within a relationship that should be focusing on the client’s concerns, it seems that this third criterion of sexual harassment would be met. In conclusion, it seems that Steven Kreft’s behaviour in this case fell far short of recognised ethical, legal and social expectations. He took on a client with issues outside his narrow expertise and attempted to work with her in relation to the highly sexualised disclosures she made about her relationships with men. Kreft’s own highly sexualised personal disclosures were unethical according to professional guidelines and potentially unlawful, under sexual harassment laws.
Kreft’s attempts to help the client change her negative beliefs about her body were devised without reference to existing knowledge in the treatment of such problems and again became sexualised when Kreft chose a photo of the client dressed only in underwear. Ultimately, Kreft was required to update his training, engage in regular supervision, and undergo a suspension of practice for six months. Kreft’s case provides a number of warnings for other practitioners about the dangers of a narrow knowledge and experience base, as well as the importance of understanding the various dimensions of therapeutic relationships. Counsellors would do well to have a sound understanding of ethical boundaries and how they might appropriately respond to a client’s disclosures of sexual behaviour. Having regular supervision is crucial for assisting counsellors in all of these areas.
Australian Counselling Association. (2012). Code of ethics and practice. QLD: Author.
Barnett, J., Lazarus, A., Vasquez, M., Moorehead-Slaughter, O., & Johnson, W. (2007). Boundary issues and multiple relationships: Fantasy and reality. Professional Psychology: Research and Practice, 38(4), 401–410. Butters, J. W. & Cash, T. F. (1987) Cognitive-behavioral treatment of women’s body-image dissatisfaction. Journal of Consulting and Clinical Psychology, 55, 6. Gurtheil, T. G. & Brodsky, A. (2011). Preventing boundary violations in clinical practice. London: Guilford Press. HCCC v Kreft (No. 1) (2011) NSWPST 2.
HCCC v Kreft (No. 2) (2012) NSWPST 1.
Pope, K. S. & Vasquez, M. J. (2011). Ethics in psychotherapy and counselling: A practical guide. New Jersey: John Wiley and Sons. Proctor, G. (2002). The dynamics of power in counseling and psychotherapy: ethics, politics and practice. Ross-on-wye, Herefordshire: PCCS Books. Victorian Equal Opportunity and Human Rights Commission. (2013a). Victorian discrimination law. Melbourne, Australia: Author. Victorian Equal Opportunity and Human Rights Commission. (2013b). Guideline: Sexual harassment. Complying with the Equal Opportunity Act 2010. Melbourne, Australia: Author. Welfel, E. R. (2013). Ethics in counseling and psychotherapy. (5th ed.). Belmont, CA: Brooks/Cole.