Sexual Feelings in the Psychotherapy Room: Comparing Their Occurrence in Patients With Unipolar Depression, Bipolar Disorder, and Neither of These

We read with interest the paper by Yaghmaei et al. [1], which highlights the significant impact of sexual challenges faced by individuals with bipolar disorder on their quality of life, as well as on their families. Their research underscores the need for early family-tailored sexual health interventions and the importance of recognizing these issues in both diagnostic and therapeutic contexts.

We agree with Yaghmaei et al. and wish to extend the discussion to another crucial aspect of the lives of these patients: the psychotherapeutic context.

Changes in the sexual patterns of psychiatric patients are evident not only within their families but also profoundly influence the therapeutic environment and dynamic. For example, behaviors such as innuendo, unsolicited sexual advances, changes in couture and make-up, and even sexual exhibitionism are notable, particularly during certain stages of bipolar illnesses. From its very beginning, the realm of psychotherapy is not immune to these erotic undertones. Most psychotherapists, at various points in their career, will experience romantic or sexual overtures from their patients. In certain situations, these advances can even evoke reciprocal feelings in the therapist. When not properly managed, such dynamics can jeopardize the therapeutic relationship, hinder treatment progress, and, in extreme cases, result in breaches of professional conduct. Although the literature suggests is it not the most common ethical violation providers are sanctioned for [2], sexual misconduct is a serious and recognized issue in the field. Herbert Strean's 1994 publication, “Therapists who have sex with their patients,” continues to be an enlightening read. Pooled data indicate that more than 4% of surveyed mental health professionals surveyed have admitted to crossing sexual boundaries with one or more of their patients [3]. Furthermore, it is crucial to acknowledge that the prevalence and types of ethical violations can vary significantly by region, cultural context, therapist's unresolved personal problems, and the specific group of mental health professionals studied [4].

A pressing question remains: Are erotic behaviors in therapy sessions more prevalent among patients with bipolar disorder compared to those with other diagnoses? The forthcoming, original data seek to shed some light on this pivotal issue.

The data presented herein are from a secondary analysis of a cross-sectional study aimed at developing and preliminarily validating a self-report inventory that assesses patients' perceptions and affective reactions to their therapists during psychotherapy sessions [5]. The sample comprised 701 adults diagnosed with psychiatric disorders, all of whom underwent individual psychotherapy and resided in the United States. Participants were recruited from March through April 2022 through two national registers for clinical research funded in part by the National Institutes of Health (NIH) National Center for Advancing Translational Sciences (NCATS): ResearchMatch and Research for Me. Most were women (80%), and the predominant age groups were 18–29 years (40%) and 30–39 years (19%). Comprehensive details on the aim, rationale, methodology of the broader study, and sample characteristics are provided elsewhere [5]. No information on the type of individual psychotherapy participants were receiving has been collected. Nonetheless, it is important to note that patients' romantic and sexual feelings toward their therapists occur across various types of psychotherapy [6].

Participants were asked to rate a series of statements describing how they felt toward their therapist during their most recent therapy session. Three statements addressed, respectively, the feelings of (a) romantic attraction to the therapist (RA), (b) sexual attraction to the therapist (SA), and (c) perceived sexual attraction from the therapist (PA). For the purpose of this report, the patients were categorized into three primary diagnostic groups: unipolar depression (54%), bipolar disorder (17%), and neither of the above (29%). Regarding comorbidity with personality disorders that may exhibit sexualized boundary testing, 21% of patients with bipolar disorder, 4% of those with depression, and 3% of individuals in the third group were diagnosed with borderline personality disorder. Additionally, only one patient from the “other” category was diagnosed with histrionic personality disorder. As the main study did not focus on bipolar disorder, information on the specific phase of bipolar illness was not collected, representing a significant limitation of this report. It can be hypothesized, however, that bipolar patients undergoing psychotherapy would likely be in a state of remission.

The prevalence rates of RA, SA, and PA were the following: 5%, 8%, and 1% for unipolar depression, 10%, 11%, and 7% for bipolar disorder, and 9%, 10%, and 6% for those without any mood disorder (see Figure 1). Univariate and multivariate regression analyzes (adjusted for age, sex, and comorbidity with personality disorders) consistently showed significantly higher odds of PA in patients with bipolar disorder (OR: 5.87; aOR: 4.80) or without any mood disorders (OR: 4.82; aOR: 4.25) compared to patients with unipolar depression. No significant differences were identified for RA and SA. Male patients had higher odds of RA (aOR: 3.90), SA (aOR: 5.90), and PA (aOR: 3.30).

Considering that the research frame focused only on the very last therapy session, this suggests a relatively high prevalence of erotic feelings toward the therapist among patients in psychotherapy. However, these feelings do not appear to be more frequent in patients with bipolar disorder than in patients with a different psychiatric diagnosis. The only exception was the odds of perceiving the therapist as sexually attracted to the patient, which was significantly lower in people with unipolar depression. It is important to note that our study did not obtain data on the specific phase of bipolar illness in which patients were at the time, although it is reasonable to hypothesize that bipolar patients engaged in psychotherapy would be mostly in remission. Distinguishing between the illness phases would likely reveal significant differences in the outcomes measured. Consistent with our findings, we hypothesize that depression suppresses sexual interest, resulting in a loss of interest during the depressive phases of bipolar disorder, which is subsequently counterbalanced by increased sexual interest during hypo/mania.

The higher odds found in male patients is clinically relevant when considering that recent findings indicate that dealing with a male patient increases the odds that the therapist experiences romantic attraction [2]. Furthermore, prior work found that dealing with a patient suffering from a mood disorder (83% of the sample was composed of patients with unipolar depression) increased the odds of feeling romantically attracted to them [3]. This could place the therapeutic dyad on a slippery slope toward boundary violation.

The clinical importance of patient sexuality within the therapeutic setting is paramount and is overlooked at the provider's peril. Future research should not only examine the prevalence of these attitudes and behaviors and their correlations with specific mental disorders and current symptoms. It is equally vital to explore the varied clinical meanings associated with different types of mental disorders. Furthermore, there is a pressing need to explore the potential to craft disorder-specific approaches to managing sexuality within the therapeutic context.

All co-authors have seen and agree with the contents of the manuscript. Dr. Eric A. Youngstrom has received royalties from the American Psychological Association and Guilford Press and consulted about psychological assessment with Signant Health. He is the co-founder and Executive Director of Helping Give Away Psychological Science, a 501c3 in the United States, where he serves as an unpaid volunteer.

Dr. Eduard Vieta has received grants and served as consultant, advisor, or continuing medical education (CME) speaker for the following entities outside the submitted work: AB-Biotics, AbbVie, Adamed, Angelini, Biogen, Biohaven, Boehringer-Ingelheim, Celon Pharma, Compass, Dainippon Sumitomo Pharma, Ethypharm, Ferrer, Gedeon Richter, GH Research, Glaxo-Smith Kline, HMNC, Idorsia, Johnson & Johnson, Lundbeck, Medincell, Merck, Newron, Novartis, Orion Corporation, Organon, Otsuka, Roche, Rovi, Sage, Sanofi-Aventis, Sunovion, Takeda, and Viatris.

Dr. Alberto Stefana, Dr. Paolo Fusar-Poli, and Dr. Pierluigi Politi have nothing to disclose.