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Countertransference and Special Concerns of Subsequent Treating Therapists of Patients Sexually Exploited by a Previous Therapist

Linda Mabus Jorgenson, MA, JD

 

Sexual contact between physicians and patients has been prohibited since the time of the Hippocratic Oath. (1,2) Over the past two decades, all major mental health organizations have declared therapist­-patient sexual contact unethical. (3-6) Yet, such contact remains surprisingly prevalent. (7) As many as 12% of therapists self-report that they have had sex with one or more of their patients. (8.12) Approximately 90% of these patients are women. (11) National studies reveal that most patients (90%) are harmed by this sexual contact. (11) One study reported that 65% of therapists have treated at least one patient who had sexual contact with a previous thera­pist. (13) Thus, most therapists are likely at some time to treat a patient who has had a sexual relationship with a previous therapist.

Sexually abused patients suffer a broad range of damages that vary according to the patient's original pathology and the circum­stances of the sexual abuse. Consequently, sub­sequent treating therapists must anticipate a number of specific therapeutic issues. Pope and Bouhoutsos describe a "therapist-patient sex syndrome" that includes feelings of guilt, ambivalence, isolation and emptiness, difficulty in trusting, cognitive dysfunction, suppressed rage, sexual confusion, identity and boundary confusion, increased suicidal risk, and emotion­al lability. (14) In a study of 30 patients who had been sexually exploited by their therapists, Kluft found major psychiatric illnesses, disso­ciative symptoms, histories of hospitalizations, and suicide attempts. (15) Additionally, he esti­mated that 92% of his patient population suf­fered from posttraumatic stress disorder. Notman noted that subsequent therapies were frequently compromised by premature termina­tion or unsatisfactory outcomes. (16) Thus, the symptomatology of the abused patient can pose special problems for the subsequent treating therapist.

The subsequent treating therapist must also proceed with caution in recognizing and understanding his or her countertransference reactions. As one commentator noted, when treating patients who were sexually involved with a prior therapist, countertransference "springs up almost immediately and more strongly than usual." (17) Often, the early appear­ance and intensity of the countertransference lead the subsequent treating therapist to become either under-involved or over-involved with the patient.

This article will explore countertransfer­ence in the subsequent treating therapist. The reactions of over-involvement and under-involve­ment of the subsequent treating therapist with the patient will be examined in particular. The conclusion will address the special needs of this class of patient and additional concerns of the subsequent treating therapist such as reporting the abuse and seeking outside consultation.

ANALYSIS OF COUNTERTRANSFERENCE

The working definition of countertransfer­ence that will be used in this analysis is the "therapist's total response to the patient, both conscious and unconscious. This 'total response' includes all the thoughts and feelings that the therapist experiences in reaction to the thera­peutic interaction whether the responses are considered to be 'real' or 'neurotically distort­ed.' "(18) The subsequent treating therapist's responses to a patient tend to fall along a con­tinuum, with over-involvement at one extreme and under-involvement at the other.

UNDER-INVOLVED COUNTERTRANSFERENCE

Countertransference in the under-involved therapist is likely to manifest as disbelief, iden­tification with the perpetrator, blaming the vic­tim, and/or counseling inaction on the part of the patient.

Disbelief

The reaction of the under-involved subse­quent treating therapist to a patient's allegation of sexual abuse is commonly total disbelief. The therapist may find the patient's story to be bizarre, undocumented, or simply incredible. The patient may also exhibit behavior that is obsessive and characteristic of significant psy­chological dysfunction. For instance, the patient is often obsessed with the perpetrator and may engage in such activities as sitting outside the perpetrator's home or office to watch who comes and goes. The patient may repeatedly call or write the perpetrator. The under-involved subse­quent treating therapist refuses to acknowledge behavior of this type as having its origin in the actions of the perpetrator. Rather, the under-involved therapist may label the patient's behav­ior as psychotic eroticized transference or hys­terical psychotic-like eroticized transference.

In addition, the abusing therapist may be a distinguished teacher, mentor, or leader in the field (19, 20); he or she may even serve on ethics com­mittees. (21) Consequently, the subsequent treating therapist may be unable to entertain the notion that such a person might behave in the manner the patient describes. The countertransference response would be to view the patient's accusa­tions as an attack on the integrity of the profes­sion. Thus, the therapist may refuse entirely to comment on the sexual abuse or attempt to mini­mize the patient's psychological harm resulting from the abuse, leaving the patient to question his or her own sense of reality.

Identification With the Perpetrator

One profile of an abusive therapist is that of a middle-aged man experiencing a midlife crisis who is attracted to a younger female patient. (22) An under-involved subsequent treat­ing therapist may identify with such a perpe­trator, particularly if the subsequent treating therapist is in the midst of his or her own midlife problems. (23) Acting on the countertrans­ference, the subsequent treating therapist may believe that the perpetrator is "in love" with the patient and relate that perception to the patient. The true psychological dynamics and exploitative elements of the relationship would, thereby, be ignored and go unexplored.

Blame

The under-involved subsequent treating therapist may blame the patient for the sexual contact in an attempt to resolve the counter­transference issues of identification with the perpetrator. This dynamic is more likely with a seductive patient or a patient who reports that he or she invited the sex. The subsequent treat­ing therapist may justify these ideas by suggest­ing that the patient has an erotic transference toward him or her. This behavior on the part of the subsequent treating therapist effectively shifts the blame for the sexual behavior from the therapist to the victim.

Inaction

An under-involved subsequent treating ther­apist may dissuade the patient from taking any action against the perpetrator, fearing that the perpetrator will retaliate against the therapist. Colleagues often frown on whistle blowing. The under-involved subsequent treating therapist may fear involvement with a licensing board, ethics committee, or court proceeding if he or she reports the abuse. If the patient discloses past sexual experiences with the earlier thera­pist during treatment, the subsequent treating therapist may advise that the patient "get beyond it" and not discuss the sexual involve­ment. In response to one patient's attempt to understand why the abuse occurred, a subse­quent treating therapist stated, "I told her this was past history and there was no point in pur­suing it any more."

OVER-INVOLVED COUNTERTRANSFERENCE

Over-involvement on the part of the thera­pist lies at the opposite end of the countertrans­ference continuum. An over-involved subsequent treating therapist may experience countertrans­ference reactions of outrage, denial of personal feelings, compensating behavior, and attempts to control the patient's reactions to the abuse.

Outrage

The over-involved subsequent treating ther­apist often reacts with outrage when first learn­ing of the sexual contact with the prior thera­pist. Such an expression of countertransference may be inappropriate for the patient's treatment needs and may impair the therapist's objectivi­ty. The over-involved therapist projects onto the patient feelings of personal betrayal by one of the profession. When this occurs, the patient may try to compensate for the therapist's feeling by assuming a caretaking role for the therapist. The consequence of such behavior might be the censoring of the patient's comments or reactions in an effort to protect the therapist's feelings.

Distancing From the Perpetrator

Over-involved subsequent treating thera­pists are unable or unwilling to acknowledge their own personal or sexual feelings toward patients. This inability is commonly expressed through actions calculated to distance the ther­apist from the perpetrator. (23.24) As one commen­tator noted, "[b)y projecting the danger onto our colleague, and condemning it there, we avoid directly facing the problem of handling sexual feelings for patients that may occur in our­selves." (17)

The over-involved subsequent treating ther­apist may use such labels as "sicko" to describe the perpetrator to the patient. (22) Such comments can deepen the victim's self-doubt and intensify the shame that results from being taken in by such a person. Conversely, the patient may expe­rience anger at what he or she perceives as an inaccurate portrayal of a still idealized prior therapist. Such countertransference expressions on the part of the subsequent treating physician can discourage exploration of the true dynamics of the abusive relationship that might eventual­ly lead to insight and understanding.

Compensating Behavior

Countertransference in the over-involved subsequent treating therapist may take the form of a rescue fantasy. As a result of this fan­tasy, the therapist may collude with the patient in a process of "splitting." In this process, the new therapist takes on the persona of the "good therapist" when contrasted with the "bad thera­pist" perpetrator. In an effort to perpetuate the fantasy, the therapist makes special accommo­dations to the patient, such as reduced fees, extended therapy sessions, or long telephone conversations with the patient between ses­sions. These therapeutic "extras" do not benefit the patient and present risky boundary issues for the therapist.

Action

The over-involved subsequent treating ther­apist may feel compelled to take up the patient's cause against the perpetrator. Serving this coun­tertransference need, the therapist may pres­sure the patient to file a complaint or take other action against the perpetrator without first exploring the patient's actual desires or best interest. If the patient does file a complaint, the over-involved subsequent treating therapist may inappropriately intrude in the process. The ther­apist may express frustration with the legal process or other aspects of the complaint proce­dure. The patient is, thus, denied the right to regain control of his or her actions and deci­sions. The therapeutic alliance becomes more akin to that which exists between a forensic expert and a client.

FINDING A MIDDLE GROUND

It is apparent from the preceding discussion that the countertransference reactions of both the over-involved and under-involved subsequent treating therapist do not benefit the patient. To maximize the benefit to the patient, the task of the subsequent treating therapist is to find the middle ground on the continuum. To this end, the primary consideration must be adequate recognition that the patient's damages were caused by the previous therapist's boundary vio­lations. The setting of clear and appropriate boundaries also becomes a priority. To avoid the risk of under-involvement, the therapist must openly acknowledge the professional impropri­eties of the previous therapist. Similarly, to avoid becoming over-involved, the therapist must not allow his or her own reaction to overshadow the patient's feelings. Perhaps most importantly, the therapist must assure the patient that no sexual contact will occur between them, ever. It is also crucial that the subsequent treating ther­apist carefully examine his or her personal motives, purposes, and biases when responding to the patient.

Subsequent treating therapists best serve their patients when they (a) acknowledge that the sexual exploitation occurred; (b) do not excuse the perpetrator; (c) acknowledge that the therapist was wrong and unethical; (d) do not expressly or implicitly blame the victim; (e) acknowledge that trust will be an important issue; (f) treat the patient in a non-authoritarian way; and (g) are empathetic and genuinely con­cerned for the well-being of the patient. The fol­lowing comparisons illustrate some of the con­siderations necessary to find the middle ground between the extremes on the countertransfer­ence continuum.

Disbelief Versus Outrage

False allegations of abuse by a prior thera­pist rarely occur. (25) Of the 2500 cases of sexual misconduct documented at the Walk-In Counseling Center in Minneapolis, fewer than 1% were classified as false complaints. Subsequent treating therapists report a slightly higher number of false complaints (4%). (26) For treatment purposes, however, it is important for the subsequent treating therapist to rely on the patient's psychic reality as opposed to focusing on establishing the objective elements of the complaint.

To come to a clear understanding of the psy­chic reality, it is important that the patient be allowed to relate the facts of the abuse at his or her own pace. When listening to the patient's account, the therapist must refrain from assum­ing anything, including the gender of the perpe­trator. The therapist also should not assume that the relationship with the perpetrator has ended, at least from the patient's perspective. One subsequent treating therapist relates: After several months of therapy, Ms. N indicated that she was having an ongoing sexual relation­ship with her previous psychiatrist, Dr. A.  Ms. N was very distraught by this, but felt that he truly cared for her and that she cared for him. She did describe having significant difficulty in under­standing how he could have such a seemingly deep relationship with her but at times treat her so casually. This began a fairly lengthy process of self-reflection and self-evaluation for Ms. N in which she began to realize how Dr. A's conduct toward her was victimizing her.

In addition, the subsequent treating thera­pist needs to listen carefully for cues used by the patient to describe abusive behavior. The range of sexual contact is broad and includes words as well as touching. Inappropriate sexual contact can be limited to verbal exchanges and, thereby, not appear as egregious as cases of sexual abuse reported in newspapers or other media outlets. This less blatant type of sexual contact can dam­age a patient just as significantly.

The subsequent treating therapist must pay close attention to the patient's conflicting feel­ings toward the perpetrator and the treatment. The pattern of feelings varies and is frequently repeated. The patient may feel a significant per­sonal loss and will need the time and space to grieve this loss. As one subsequent treating therapist noted after a year of therapy: Ms. P continued to report very ambivalent feel­ings about the relationship. Over the course of several months, her mood vacillated from week to week, going from intense anger to intense dependence and back again. She described feel­ing very manipulated by him on occasions while, at other times, feeling that he was truly trying to relate to her. By late April, she had found the strength to confront him, but still found herself wanting to please him and not make him upset because she was afraid of his power over her. She continued to find him quite cold and distant toward her on some occasions, yet quite conciliatory and appeasing to her on other occasions. Over the course of the therapy, she began remembering what she felt were many of the ways that Dr. B had manipulated her.

The under-involved subsequent treating therapist, by being withdrawn and expressing disbelief, may cause the victim to submerge or ignore the exploitation, and thus fail to obtain treatment for his or her damages. The over-involved therapist's outrage may not allow the patient the freedom to expose his or her conflict­ing feelings, depriving the patient of needed sup­port, or burdening the patient. Either reaction—­disbelief or outrage—is inappropriate for the subsequent treating therapist.

Identifying Versus Distancing

Commentators have identified three main groups of abusive therapists: psychotic, antiso­cial, and "lovesick." These groups are described as follows: The psychotic group represents a very small subset of all offenders ... The number of abusing therapists with antisocial features is consider­ably larger. These individuals are ruthless, are without remorse or empathy for their victims, and are the most frankly exploitative ... Of the three groups, the lovesick (a broad category sub­suming "normals," neurotics, and assorted per­sonality disorders) are at once the most inter­esting and most puzzling. How is it that reason­ably well-functioning professionals become involved in a highly pathological and unethical relationship that can destroy their career and severely harm their patients under the guise of "true love?" (22)

The subsequent treating therapist may sometimes experience sexual feelings toward the patient that can translate into empathy with the perpetrator. Eighty-seven percent of therapists report being sexually attracted to one or more of their patients and more than half feel guilty about the attraction. (27) Sexual attraction to a victim of abuse provokes additional guilt. (28) Under-involved subsequent treating therapists may react to their sexual feelings by withdraw­ing from the patients. Consequently, the treater may feel confused and guilty; the patient may feel isolated and abandoned. Similarly, thera­pists who are over-involved should be aware of their sexual feelings to avoid becoming sexually involved with patients.

Blame versus Compensation

The therapist who blames the patient for the sexual contact aggravates the patient's pre­senting problems. Most patients who have been sexually exploited by a therapist blame them­selves for the abuse. The patient feels guilt and shame. The therapist must tell the patient that the perpetrator's behavior was unethical and emphasize that it was always the therapist's responsibility to abstain from sexual contact. The subsequent treating therapist must also remember that a seductive patient is never to blame. (12) This concept is perhaps best clearly understood by analogy: If the patient is a masochist and asks to be beaten, it is always the responsibility of the therapist to refrain from beating the patient. (29) At the other end of the spectrum, therapists who attempt to compen­sate for past bad therapy risk sliding down the slippery slope of boundary violations. Boundary violations were likely precursors to the previous therapist's sexual contact with the patient, and may in and of themselves, traumatize the patient. (30-35)

Inaction Versus Action

The therapist must always remember that the patient's needs come first. When advising a patient about taking legal action against an abusive therapist, the subsequent treating ther­apist must clearly communicate his or her motives or biases. As another subsequent treat­ing therapist observed: As it is with many victims, it is my impression that Ms. P spent the first year following her vic­timization trying to protect the psychiatrist's reputation, job, and family life. In the past 2 to 3 months, I have found that she has become much more aware of her anger regarding the relationship. She has become much more in touch with how he set her up to gratify his own sexual needs and impulses. Part of this process has been her wrestling with how to handle the fact that she was sexually violated by her psy­chiatrist. Over the spring, she began breaking the bonds of secrecy that Dr. D had made her promise to keep. She is now interested in filing a Board complaint.

In the final analysis, the decision about whether to pursue action must be the patient's.

SPECIAL CONSIDERATIONS FOR SUBSEQUENT TREATING THERAPISTS

Patients who have been sexually exploited by therapists bring some special problems to any subsequent therapeutic treatment. As stat­ed earlier, feelings of guilt, confusion, rage, and an inability to trust are some of the damages suffered by these patients. A clear understand­ing of these signs and symptoms of injury can prove invaluable in reaching the middle ground described above. Therefore, the subsequent treating therapist should be prepared to con­front one or more of the following manifesta­tions of injury in the patient.

Distrust

At the outset of the therapy, the subsequent treating therapist must determine the extent of the patient's inevitable distrust of therapists and the therapeutic process. The patient's dis­trust is founded on real past experience, and it must be acknowledged rather than patholo­gized. At the same time, the subsequent treating therapist must convince the patient that he or she will not abuse the patient and will erect and maintain appropriate therapeutic boundaries.

The therapist also must determine which therapeutic modality best suits the patient. A sexually abused patient may, for example, be unable to tolerate the intimacy necessary for individual psychotherapy. Therefore, group psy­chotherapy or a support group may be more appropriate for such a patient. The gender of the therapist might pose a concern, and the patient may feel more comfortable with a therapist of his or her own gender or the opposite gender from the perpetrator. Whatever the therapeutic setting, the therapist must keep the issue of trust at the forefront and reevaluate it con­stantly.

Transference Issues

Transference of feelings for the former ther­apist onto the current therapist can be expected, thereby distorting the normal transference process. The patient is likely to displace anger, as well as other ambivalent feelings toward the abuser, onto the therapist. The patient who is experiencing overwhelming feelings of guilt and shame may express these feelings by projecting a sense of personal helplessness and the use­lessness of the therapeutic process onto the sub­sequent treating therapist. The patient's atti­tude may be "no one can help me deal with what happened." The patient's transference may be so distorted by the effects of the previous therapy that "there may be no semblance of a rational therapeutic alliance."

Ambivalence Toward Perpetrator

Like victims of spousal abuse or incest, patients who have experienced sexual contact with a therapist may cling to feelings of attach­ment to that therapist. If the perpetrator social­ly isolated the victim, the abuser could be the patient's only source of emotional support. In addition, the patient may hold onto the positive feelings of the relationship in an attempt to shield himself or herself from erupting in a dis­ruptive rage. The subsequent treating therapist must maintain therapeutic neutrality, strive to understand the patient's attachment to the abu­sive therapist, and never attempt to force dis­ruption of the attachment.

Reenactment of the Abuse

Victims of sexual abuse often attempt to regain control by recreating the prior trauma. A subsequent treating therapist should anticipate this behavior on the part of the patient and be aware of signs that the patient is luring the therapist into the role of the victimizer. This sadomasochistic and sometimes sexual interac­tion is often played out in minor transactions that go unnoticed unless the subsequent treat­ing therapist is prepared for them. Subtle meth­ods of extracting unreasonable compliance fol­lowed by intense anger may signal such enact­ments.

Despair

Victims of sexual contact with therapists occupy a special position vis-a-vis the mental health system. They have recognized problems in their functioning and have sought help for those problems. Their efforts, however, have failed through no fault of their own. These patients may now feel profoundly demoralized, frustrated, and helpless. Depression, therefore, is often a serious problem and constant compan­ion in subsequent therapy. Often, antidepres­sant drug therapy is necessary. It is not surpris­ing that victims have a higher-than-expected suicide rate. The therapist must carefully moni­tor this risk. Patients should be encouraged to identify and use all available supports, includ­ing social, community, and family resources.

Guilt

Intense guilt and self-blame are often byproducts of sexual abuse. These feelings may be compounded by the disbelief of those close to the victim or other actions that place the blame on the victim. The victim's self-esteem may be so damaged by the blaming process that he or she feels deserving of the misery being experienced. The patient's guilt can also prevent insight into the dynamics of the victimization and make it difficult to identify and develop the skills neces­sary to avoid future harm. Therefore, it is impor­tant that the subsequent treating therapist con­sistently place responsibility for the ethical violations on the perpetrator.

ADDITIONAL CONCERNS

Reporting the Abuse

The subsequent treating therapist fre­quently questions whether to report the prior abuse of the patient. Few states mandate report­ing. (36) In most states, however, communication between therapist and patient are privileged. This means that the therapist may not reveal a patient's communications during therapy to any other person except with the patient's express permission, or under very restricted circum­stances. (37, 38) In states that do not mandate it, reporting should not be done without the patient's written permission. (36) The decision about whether to report the abuse ultimately rests with the patient.

Seeking Legal Consultation: The Patient

If the patient decides to pursue a legal claim against the perpetrator, the subsequent treating therapist should encourage the patient to con­sult with a forensic psychiatrist or a plaintiff’s attorney who specializes in sexual misconduct cases. The consultation is important for the patient to understand his or her legal rights. The patient should know all available options before proceeding: doing nothing; mediation; reporting to the hospital, a professional society, or a Board of Registration; or filing a civil or criminal complaint. The subsequent treating therapist, however, should not assume the dual role of treater and expert because of the danger that the therapeutic alliance would be impaired.

The time within which the patient must bring legal action is governed by the statute of limitations, which varies by jurisdiction. (39, 40) Recommending therapy with a subsequent treating therapist may trigger the running of this time period. For example, in Massachusetts, the statute of limitations begins to run when the patient "discovers" or should have discovered that he or she was harmed and that the thera­pist's actions caused the harm. From that point, the patient has 3 years to bring suit. It is often argued that a patient who seeks further treatment and reveals the previous therapist's misconduct to the subsequent treating therapist exhibits some knowledge of his or her harm and the therapist's role in it. It is important for the patient to be aware of this.

Consultation can help the patient become informed about his or her options. The patient must be told how intrusive a legal action can be. For example, in a lawsuit for emotional harm, the notes of the subsequent treating therapist will be discoverable by the defendant's lawyer during pretrial proceedings.

Seeking Legal Consultation: Subsequent Treating Therapist

The subsequent treating therapist may also wish to consult a lawyer or forensic expert con­cerning his or her own obligations should the patient decide to instigate legal action against the perpetrator. For instance, the subsequent treating therapist might seek clarification of testimonial privilege and confidentiality issues in the event that records are requested or testi­mony sought. In addition, a perpetrator's defense might focus on the subsequent treating therapist's role in causing or increasing the patient's harm. The perpetrator may also argue that the subsequent treating therapist con­vinced the patient to file a complaint, thus wors­ening the patient's condition. The subsequent treating therapist may be forced to defend against these charges; consultation can assist the therapist in anticipating these issues. (41)

Legal Obligations Regarding Treatment Records/Confidentiality

Because of the possibility that treatment records will be subpoenaed, the therapist should maintain therapy notes with full awareness that they might be viewed by the patient, attorneys, the perpetrator, and others. Also, because the damages resulting from the abusive therapeutic relationship are an issue in a legal action, the notes should indicate when the patient first con­sulted the subsequent treating therapist and what the patient's immediate needs were. The subsequent treating therapist might also keep in mind that the patient's expert will rely on these notes to formulate his or her testimony concerning the patient's damages.

PROFESSIONAL CONSULTATION

Because subsequent therapy efforts so com­monly flounder or terminate prematurely, the subsequent treating therapist must anticipate the need for consultation to successfully treat the patient. For instance, the subsequent thera­py may become "stuck." A third-party supervisor or consultant could provide perspective on transference-countertransference issues or sug­gest ways to overcome therapeutic impasses.

CONCLUSION

Patients who are sexually abused by prior therapists present special challenges to subse­quent treating therapists. Throughout the rela­tionship, the subsequent treating therapist must be aware of his or her countertransference reactions. Countertransference reactions must be carefully monitored for evidence of under-in­volvement or over-involvement. By anticipating distortions of countertransference and devising a plan to work through these reactions, the sub­sequent treating therapist can increase the like­lihood of a successful therapeutic alliance.

When appropriate, the subsequent treating therapist should be prepared to refer the patient for a consultation with a forensic expert or knowledgeable attorney to assist the patient in understanding his or her legal options. The sub­sequent treating therapist must anticipate the signs and symptoms commonly associated with therapist sexual exploitation and be prepared to confront them head-on. Finally, the subsequent-treating therapist must always be mindful of his or her primary role, i.e., that of healer.

 

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39. Jorgenson LM, Appelbaum PS. For whom the statute tolls: extending the time during which patients can sue. Hosp Community Psychiatry. 1991;42:683-684.

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© Copyright 1995 Linda Mabus Jorgenson

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