Therapists must also be sensitive to their primarily unconscious emotional responses to the patient—countertransference—which can also present a danger to patients. In a strict sense, this is the therapist’s transference to the patient; that is, the therapist reexperiences feelings, thoughts, and behaviors toward the patient that have their origin in the therapist’s past relationships. More generally, the term countertransference refers to the totality of the therapist’s conscious and unconscious thoughts, feelings, and behaviors toward the patient. For example, the therapist’s countertransference to the patient may contain compelling erotic, incestuous feelings from early childhood that may be currently fueling a sexual interest toward a prohibited person—the patient. As with transference, countertransference exists in all relationships but is a particular problem in professional interactions. It can fuel the therapist’s temptation to exploit a position of power and commit sexual misconduct. As former secretary of state Henry Kissinger once observed, “Power is the great aphrodisiac.”
The inevitable countertransference feelings induced in the therapist regarding the patient can become a therapeutic window into the conflicts of the patient and into his or her characteristic ways of interacting with others. Insights gained through examining countertransference can assist the patient’s recovery. But countertransference feelings, particularly of the erotic variety, can also be occasion for the therapist mismanaging the patient’s treatment. Therapists get into trouble with patients when they are unable to hold, contain, and analyze their own feelings toward the patient. This is what the medical board in Massachusetts alleged had happened with Dr. Bean-Bayog, as they pinpointed her failure “to terminate or otherwise address” her sexual fantasies evoked in the treatment of Paul Lozano. The board found that her inability to deal with these issues was unacceptable.
Sexual exploitation of patients does not necessarily arise from transference or countertransference. Some therapists are—plain and simple—predators who pounce on vulnerable individuals. These therapists usually have severe malformations in their character and personality. In general, therapists who undertake long-term psychotherapy with patients should undergo their own psychotherapy or analysis, although this is not an absolute prerequisite. But the therapist must have or develop the ability to turn his or her mind on itself for the purpose of understanding personal problems, particularly in relation to the treatment of other people. For example, the lure for the therapist of having illicit sex with patients often has its roots in the therapist’s early incestuous desires. Understood and controlled, these feelings can prove useful in alerting the therapist to the nature of the material coming from the patient that may be stimulating incestuous feelings in the therapist. Misunderstood and uncontrolled, the feelings may lead to therapist-patient sexual misconduct.
With psychotherapists especially, the notion that bad men do what good men dream is of the essence. This notion is confirmed by a study showing that whereas 95% of the male psychotherapists and 76% of the female psychotherapists among 575 surveyed felt sexually attracted to their clients, only 9.4% of the men and 2.5% of the women acted on such feelings. Other studies show that nearly 75% of therapists have had sexual fantasies about a patient and 58% have become sexually aroused during therapy. Slightly more than 25% have had fantasies about a patient during sex with someone else.
When the Therapist Is a Woman
A significantly lower incidence of sexual misconduct by female therapists is a consistent finding of many surveys. Among those female therapists who do become sexually involved with their patients, the most common form of involvement is heterosexual relationships. Some female therapists, however, do develop what have been described as “tea and sympathy” relationships with female patients. These therapists are usually heterosexual and become overinvolved with the patient and overidentify with the patient’s problems. Their offers of tenderness and closeness may turn into hand-holding, kissing, fondling or even suckling the patient.
Numerous reasons (though not necessarily accurate ones) have been proffered to explain the lower incidence of sexual misconduct by female therapists:
• A strong mother-son incest taboo is unconsciously operating in the therapy, for both parties.
• Female therapists tend to have practices in which a higher proportion of their patients are women and children.
• The effects of maternal-child feelings generated by the treatment are sexually inhibiting for both parties.
• Women have been acculturated into nonpredatory roles; there is no female equivalent of the “macho” man’s role.
• Gender differences in the biological bases of aggression (e.g., the presence of more testosterone in males) affect incidence of sexual misconduct.
• The female therapist’s response to desperate, needy patients of the opposite sex is less likely to be erotically tinged than is the male therapist’s response because of acculturation and gender differences.
• Female therapists who are older are less likely to view themselves, and to be viewed, as sexual beings within the treatment context.
• Females, as a group, are more compassionate, nurturing, sensitive, and empowering of others.
Treatment Boundaries and the Slippery Slope
All professions establish professional and ethical guidelines for the conduct of their practitioners. For example, the Hippocratic oath taken by all physicians states primum non nocere—first, do no harm. The purpose of such guidelines is not only to protect the consumer from exploitation but also to provide good care. That is certainly true in the mental health field. All psychiatric therapies, regardless of their philosophical or theoretical orientation, are based on the fundamental premise that the therapist’s positive interaction with the patient is aimed toward alleviating psychic distress, positively changing the patient’s behavior and, in a meaningful way, altering the patient’s perspective on the world. In short, the therapeutic equation is a unique opportunity for a patient to obtain much-needed help. Exploitation of patients by therapists destroys this potential.
There are basic guidelines for the maintenance of treatment boundaries that are commonly accepted by most therapists. The concept of treatment boundaries, in fact, began in the twentieth century, largely as an outgrowth of psychoanalysis and psychodynamic psychotherapy. As early as 1909, the founder of psychoanalysis, Sigmund Freud, strongly disapproved of his disciple Sandor Ferenczi’s sexual involvement with his patient “Frau G” and her daughter “Elma.” Treatment boundaries were further defined by the ethical principles developed by the mental health professions and by the legal duties imposed on therapists by courts, by statutes, and by regulatory agencies. As a case in point, the therapist’s duty to maintain the patient’s confidentiality derives from three distinct sources: good professional care, ethical codes, and legislative mandates. Treatment boundaries are set by the therapist and not by the patient. It is the therapist’s professional duty to establish and maintain boundaries that define and secure the therapist’s professional relationship with the patient. Sound boundaries promote a trusting working relationship between therapist and patient.
Psychiatry continues to be highly receptive to innovative treatments that offer the hope of helping the mentally ill. But what is an inviolable treatment boundary to one “school” of psychotherapy may seem like nonsense to another. Some people fear that restricting treatment boundaries can pose impediments to therapeutic innovation. The new hope for helping the mentally ill, they argue, depends on innovative and possibly boundary-defying techniques. I am not persuaded by that argument, nor do I believe that maintaining basic treatment boundaries is any impediment to responsible innovation.
Rules, however, cannot always be hard and fast. Exceptions exist for mental health professionals practicing in small communities and rural areas, who encounter unique situations and customs that may require appropriate adjustments of treatment boundaries—for example, where “everybody knows everybody else.” There is a gen
eral boundary guideline that physical contact between therapist and patient should be minimized. In the case of alcohol and drug-treatment programs, an exception to this rule must be made because part of the therapeutic process is the hugging of patients. Also, therapists who work with children, the elderly, and the physically ill frequently have need to touch their patients. As long as this is done in a nonerotic, clinically supportive manner, it is appropriate to the treatment process. In every instance, when trying to fashion a boundary for treatment, what needs to be taken into account is the nature of the patient, the therapist, the type of treatment, and the status of the relationship between therapist and patient. Despite the wide variety of psychological treatments, a general consensus does exist among practitioners concerning the necessity of appropriate treatment boundaries. There is never a circumstance in which “anything goes.”
As a forensic psychiatrist, I have had the opportunity to review a number of sexual misconduct cases sent to me by lawyers. Almost without exception, I have found that treatment boundaries are not violated suddenly, except in the reported instances of forcible rape. Rather, the violations are gradual and progressive—especially those that lead eventually to sexual intimacy. Sometimes the erosion of the boundary is barely noticeable. Even if sexual relations are not the eventual end product of the boundary violations, other sorts of exploitation may be produced. The patient may be used to provide services or to perform chores for the therapist. The therapist may involve the patient in business dealings, exploiting the patient monetarily. It is my experience that patients are more frequently exploited over money than sex. Sometimes it is both. All such boundary violations invariably impede or destroy the patient’s treatment.
Therapists who are boundary sensitive may breach a barrier in a minor way, then awaken to the fact that it is being violated and take actions to properly restore the treatment boundaries. But there are therapists who are not boundary sensitive. With them, what is the patient to do? In many instances, the patient may feel that a boundary is being violated but may not be able to escape from a therapy that is heading toward sexual exploitation. Consider the following case:
A 56-year-old male therapist began individual psychotherapy of a 32-year-old woman who was attractive, divorced, and depressed. Just prior to starting this therapy, the therapist had recently concluded a bitter divorce that ended his 25-year marriage. During the initial 6 months, the therapy progressed and treatment boundaries remained intact. Thereafter, an easy familiarity blossomed between the therapist and patient, who had started to address each other by their first names. A handshake at the end of a session replaced the simple goodbye that had been the standard at parting. The tenor of the therapeutic sessions became more social, with mutual sharing of experience. On one occasion, the psychiatrist talked about his divorce and loneliness. On another, he shared his sexual fantasies and dreams with the patient. She responded by describing the various social functions available to divorcées. The handshake at session’s end progressed to a hug. Then, in their embraces at the end of each session, the therapist and patient began to linger. Because the patient felt she was receiving special attention from the therapist, her depression appeared to improve dramatically. She stopped questioning some of the therapist’s behaviors toward her that were initially troubling. In due course, the patient’s sessions were scheduled for the end of the therapist’s day when they could spend uninterrupted time together. Before long, therapist and patient occasionally dined together. Movie dates followed, with hand-holding and kissing. Eventually, a sexual relationship “just happened.”
It did not “just happen,” of course: the sexual relationship was but one more, albeit critical, boundary violation in a series that had begun almost imperceptibly. In the case example, the sex was the culmination of many earlier, progressive boundary violations. Boundary violations frequently begin insidiously “between the chair and the door.” During this segment of the therapy session, patients and therapists are more vulnerable to committing boundary crossings and violations. Therapists must be aware of the potential for boundary violations to begin during this interval when both patient and therapist can slip into a social relationship. Studies also show that therapist self-disclosure of personal information to the patient, particularly of sexual fantasies and dreams, is highly correlated with eventual sexual misconduct. Therapist-patient sex is never the only deviation in the patient’s care. There are invariably other transgressions, many of which are not explicitly sexual: for example, medication mismanagement, failure to correctly diagnose, breach of confidentiality, poor record keeping, improper billing. Consider the following instance:
A 38-year-old single woman with symptoms of generalized anxiety entered therapy with a 41-year-old male therapist. Unbeknownst to her, this therapist had sexually exploited several of his other female patients. This patient suffered from very low self-esteem and had a great need to please others. The therapist diagnosed the patient as having dependent personality disorder. He prescribed for the patient a combination of psychiatric drugs that had the effect of keeping the patient oversedated much of the time. Within a few months of having started once-weekly psychotherapy, the patient was returning the therapist’s library books for him “as a favor.” Gradually, the therapist convinced the patient to do other menial chores. When the patient began having trouble paying her treatment bill, she agreed with the therapist’s suggestion that as partial payment she clean the therapist’s office twice a week. Because her therapy sessions were scheduled at noon, the patient agreed to fetch the therapist’s lunch before each session from a nearby delicatessen. If the lunch was unsatisfactory, the therapist would scold the patient. He also frequently expressed displeasure with the way she cleaned the office. Fearing rejection, the patient gradually slipped under the therapist’s total control. The last vestiges of supportive psychotherapy vanished. When the patient appeared crushed by the therapist’s criticisms, she would be directed to sit on the therapist’s lap, where he would stroke and rock her. By then totally dependent on her therapist, the patient was emotionally incapable of resisting his subsequent sexual advances.
Patients with low self-esteem and intense rejection sensitivity are easy marks for unscrupulous therapists. In this case, the sexual activity that occurred relatively late in the patient’s “treatment” can be seen to be within the context of increasingly serious deviations from the norm in care of the patient. Treatment boundaries were gradually but inexorably breached as the therapist gratified his own needs through exploitation of the patient. Oversedation was done primarily to attain control over her. Abuse of medications occurs in a number of malpractice cases that also allege sexual misconduct. In this particular case, the patient’s mind was repeatedly raped before her sexual abuse ever began.
Another case presents a different type of breach:
A 61-year-old male therapist had been treating a 48-year-old woman for marital problems for approximately 1 year. During this year, he saw the patient twice weekly for supportive and insight psychotherapy sessions. The year before treatment began, the therapist had lost his wife to a lingering illness. As the woman’s treatment progressed, the therapist gradually began to share more of his own thoughts, feelings, and experiences with the patient. Just as gradually, she took on a supportive, confidante role with him. Occasionally, when speaking of his dead wife, the therapist would break down and cry. When this occurred, the patient would place her arm around the therapist and reassure him in a soothing voice. Most of the sessions became devoted to the therapist’s problems. Eventually, the therapist and patient began to see one another outside of the therapy sessions. The therapist’s depression improved. As for the woman, feeling neglected in her own marriage, she now found renewed meaning in her relationship with the therapist. She assumed the position of a doting maternal figure for the therapist. When sexual relations occurred between them, these were secondary to the caretaking role of the patient. The complete switching of positions of therapist and pat
ient had been achieved.
Basic Boundary Guidelines
Psychotherapy is an impossible task. It cannot be done perfectly. In psychotherapy, boundary issues inevitably arise from the patient and form an essential ingredient in the treatment. Boundary violations, however, are another matter, for these arise not because of the therapeutic situation but because of the therapist. They are damaging to the treatment process, particularly if they go unchecked and if they become progressively more serious. Unrestrained, progressive boundary violations usually reflect the acted-out conflicts of the therapist. Incidents of boundary violation, often called boundary crossings, that are both brief and quickly recognized and rectified by the therapist can provide important insights into conflictual issues for both the therapist and the patient. An example: the therapist begins to self-disclose, then checks himself. The patient asks why the therapist stopped. The therapist turns the question around and asks the patient about why he wants to know more about the therapist. This leads to a helpful discussion about the patient’s resistance to self-scrutiny.
Several basic, interlocking principles provide the underpinning for the establishment of boundary guidelines. One is the rule of abstinence. The therapist must refrain from obtaining personal gratification at the expense of the patient. It is understood, in consequence of this rule, that the therapist’s main source of personal gratification comes in the form of the professional pleasure derived from the psychotherapeutic process and the satisfactions gained from helping the patient. The only material gain obtained directly from the patient is the fee for the therapist’s professional services. Other principles underpinning the guidelines include the therapist’s duty to maintain therapeutic neutrality, to support patient autonomy and self-determination, to uphold the fiduciary relationship between therapist and patient, and to respect human dignity. Out of these principles, the following general guidelines have been elucidated as a necessary treatment frame for the conduct of most psychotherapies:
Bad Men Do What Good Men Dream: A Forensic Psychiatrist Illuminates the Darker Side of Human Behavior Page 23