Bad Men Do What Good Men Dream: A Forensic Psychiatrist Illuminates the Darker Side of Human Behavior (30 page)

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 general 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 patient 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:

• The therapist maintains relative therapeutic neutrality, withholding his or her own personal views.
• The therapist fosters the independence of the patient by maintaining the patient’s psychological separateness from the therapist.
• The therapist preserves the patient’s confidentiality, an essential element of trust in psychotherapy.
• The therapist works collaboratively with the patient and obtains informed consent for treatment and procedures.
• The therapist interacts with the patient primarily through talking.
• The therapist takes pains to ensure that there are no previous, current, or promised future personal relationships with the patient.
• The therapist makes sure to minimize physical contact with (and possible erotic stimulation of ) the patient.
• The therapist avoids burdening the patient with personal disclosures and preserves relative anonymity.
• A stable fee policy is established, and the therapist accepts only money as payment for treatment.
• A consistent, private, and professional setting is provided for the therapy—usually, a therapist’s office.
• Length and time of sessions are clearly defined. Stability and consistency are therapeutically important. Also, clear time definition of sessions eliminates the possibility of extended sessions that may be a part of progressive boundary violations.

Many of these principles and guidelines apply equally for all physician-patient, lawyer-client, pastor-parishioner, and other professional relationships.

The Therapy Predators

Based on my experience assessing what has happened in many cases of alleged sexual misconduct, I can divide the exploitative therapists into five main types: 1) personality disordered, 2) sexually disordered, 3) incompetent, 4) impaired, and 5) situationally stressed. These categories often overlap. I cannot speak authoritatively for all professions, but it is likely that groups such as lawyers, professors, and clergymen contain similar clusters of exploitative individuals.

Predator
therapists are the repeaters, those who sexually exploit numerous patients. These therapists usually display manipulative and exploitative characteristics of a borderline, narcissistic, or antisocial personality disorder. Approximately 40% of the therapists who abuse a patient have abused more than one patient under their care.
Sexually disordered
therapists are often likely to be repeaters as well. They are subdivided into three categories: frotteurs (compulsive sexual touchers), pedophiles (who use children as sex objects), and sexual sadists.
Incompetent
therapists may be poorly trained or have persistent boundary blind spots. Sexual misconduct, however, occurs at all levels of training and of professional experience.
Impaired
therapists’ mishandlings of patients can be traced to abuse of alcohol, drugs, or their own mental or physical illness.
Situationally stressed
therapists are those who because of painful personal circumstances—such as the loss of a loved one, the experience of marital discord, or a professional crisis— may turn to the patient for repair of their psychological wounds.