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.
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.
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.
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.
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-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.
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.
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.
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 reactiondisbelief or outrageis 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.
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 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.
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.
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.
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.
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.
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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Linda Mabus Jorgenson
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