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2002 March/April (9)

Friday, 02 January 2009 11:09

Everybody's Business

Written by meghan oconnell

 

 

Everybody's Business

There Are Few Secrets in a Small Town

by Jan Michael Sherman

When my wife, Denise, and I moved to a place in the Yukon so small that when someone sneezed at one end of town, someone at the other end reached for the Kleenex, I quickly found that practicing therapy could get pretty tricky. Not only did everyone know everyone else's business, everyone was in everyone else's business. Case in point: because I chose to drink only Diet Pepsi when out in public, word soon spread that I was a recovering alcoholic.

The place in question was a spot in Canada straddling the Alaska Highway just north of the British Columbia-Yukon border that I'll call Mile 666. Home to some 1,600 souls, mostly fugitives from "down south," these were folk for whom the normal overload of urban life felt too much like being buried alive. Denise and I had planned to stay two years, but ended up staying five. Something about the stillness and serenity of the winters--and only three stop signs in town--proved difficult to abandon.

Denise caught on as a medical assistant with the local doctor, while my canine cotherapist, Grizz, and I ran a branch office of a family services agency. I reported, by phone mostly, to a supervisor in Whitehorse, 300 miles and a five-hour drive to the northwest.

In a town so small, the standard therapeutic ban on "dual relationships" was impossible to observe. I quickly came to know almost everyone. And almost everyone knew me. My first client, for instance, was Susan, who bagged my purchases at the Grubstake Grocery and also happened to collect the rent on behalf of Burl, her common-law husband who owned the house Denise and I lived in.

 

Early on, I decided to deal with clients in public reactively: if someone said hello, I'd say hello. The approach worked fine, except when I happened to have awkward, multiple chance encounters (in the same day) with some client who'd had an especially intense session earlier. Even Grizz discovered there were clients she had to pretend she didn't know when she encountered them away from the office. But that wasn't enough to keep me out of trouble.

One crisp September day, a logging show operator named Gary walked in, telling me he'd parked some distance away to approach my office from the rear. He'd been concerned that his truck would be recognized--thus announcing to everyone in the damn territory that he was seeking help from "the town shrink." I found it tough to maintain a straight face given that his wife, Flora, had urged him to seek counseling while they were in the produce section of the Grubstake three days earlier; her "suggestion" had been broadcast in a nicotine-cured rasp that could cut glass at 40 paces. (I got the  news from Hoser, the town taxi driver--notorious big-mouth and non-recovering alcoholic--who'd driven Flora to bingo that same evening.)

Gary himself was a straightforward, easygoing guy who loved the Yukon as much as Flora couldn't stand it. Flora was big-city raised, had come to loathe the north and was determined to sell off Gary's business and move back to civilization. Upset about matters existential she couldn't quite put her finger on, Flora had decided to locate the source of her frustrations in her husband, and had cajoled him into getting a bit of counseling.

The first ethical problem was that I already knew Gary, sort of. Soon after arriving in Mile 666, I'd gone fishing with him. Unacquainted with the sometimes-convoluted ethics of our profession, Gary was surprised when I told him it would be inappropriate for me to see him professionally, given our preexisting relationship, ephemeral as it might be. I suggested he contact our main office in Whitehorse. But the next day, Gary called to let me know that it would take three months to be seen at Whitehorse, which would put his first session sometime in November, meaning he would have to make -the 10-hour (round trip) trek in -30o - 40oC weather. By that time, he told me, his marriage to Flora might well be history. He couldn't understand why he couldn't see me, since I was the only game in town.

 

To add a dash more dilemma to my ethical queasiness, Flora and Denise had become chummy as a consequence of Flora's frequent visits to the medical clinic where Denise worked. I told Gary I needed a little time to consider the situation. As soon as the door closed, I reached for the phone and then recalled that my supervisor was down south for a conference. Agreeing with myself that delivering needed services in a timely fashion superceded rigorous conformity to standards of ethical practice created by people who had never lived in a place like Mile 666, I booked Gary a first, formal session.

Meanwhile, the three of us prepared for our first winter. Denise made freezer jam and looked after the plants, and I split and packed logs for the wood stove, while Grizz supervised the arrival of her winter coat. One night, we went to the Tundra Room to hear the Rockin' Thunderbirds. I ordered a couple of beers to grease the grapevine--hoping to confound the rumor about my being a recovering alcoholic. I figured news of my "relapse" would be all over town come morning. (And I was right.)

A Suspicious Wife

A few weeks later, I picked up the phone to hear Flora's nicotine rasp, insisting in great distress that she needed to see me. Flora was 30 minutes early and started to cry almost as soon as she walked into my office. Apparently, about a year earlier, not long after she'd begun lobbying for them to pack it in and leave the Yukon, Gary had gone missing from the physical side of their marriage. After six months without making love--not due to any lack of desire on her part--Flora began to suspect that Gary was "carrying on." She started monitoring his movements, checking his odometer and generally feeling like she was losing it. Gary had denied any extramarital activity, but in a way that served only to fuel Flora's suspicions.

 

Two days later, at their first couple's session, Flora quickly confronted Gary. His denial sounded like a prelude to a confession, an invitation to tease the truth out of him, but Flora was in no mood to indulge his manipulations. She was the injured party here, not bloody Gary, so she'd be damned if she were going to make it easy for him. She wanted him to take full responsibility for his actions and then they'd see what they would see.

Six days on, the plot thickened considerably. I received a call from Susan (my grocery bagger and landlady) requesting a session, her first in several months. Getting right to it, Susan said that she and Gary had just ended a yearlong affair, unable to bear the guilt and shame any longer. But that wasn't why Susan had booked the session.

It seems common-law hubby, Burl, had taken her confession badly. Burl, who worked for Gary as a tree-faller, had cooked up a plan to teach Gary a lesson. Burl intended to stage a "logging accident" somewhere deep in the bush. All he'd told Susan was that he was going to lure Gary to the top of a cedar in the most remote part of the logging show, then hang him by his feet and abandon him to the tender mercies of the elements. Susan wasn't certain he'd go ahead with it; after all, Gary and Burl had been best buddies forever. Burl wouldn't actually harm Gary, would he?

I told her Burl and Gary's friendship was irrelevant. If I believed Burl's threat was serious, I'd have to report it to the Mounties--or, at the very least, warn Gary. Susan begged me not to, saying she regretted having told me about the situation. I asked if this was truly how she felt. After a moment, she shook her head: No, of course not. But wasn't there some other way we could handle it?

 

This was an ethical minefield beyond anything I'd been taught about in school. I mean, here I was negotiating with a client (Susan), on behalf of my landlord (Burl), about another client (Gary) and his wife (Flora), who's not only a client as well but the disclosure-prone buddy of my wife (Denise). Talk about needing a program to tell the players!

Well, I suggested to Susan, if the four of you came in for a session and Burl was prepared to tell Gary of his plan, that might suffice. Of course, I would need to tape the session. Susan nodded and said she'd talk to the others.

A couple of days later, Susan called to say that Burl had agreed to the "group" session after she'd told him I'd have to speak to the Mounties if he didn't. But she simply couldn't approach Flora or Gary--she just couldn't be the one to broach the affair. Couldn't I please invite them?

Out on a Limb

I could and I did. Interestingly, neither Flora nor Gary asked about the session's agenda.

A day later, the five of us met for several hours. Figuring that her cofacilitation might be counterproductive, I left Grizz at home. I felt the couples needed to stand in the fire of their threatened connectedness, to confront their fears and half-hidden truths without the ameliorating effects of canine comfort and compassion. Personally, I decided to be more Perlsian than Rogerian.

At first, there was much throat-clearing, exchanging of furtive glances and maintaining a safe distance--no one sat next to his or her partner. I was more anxious than anyone. Finally, I blurted out entirely spontaneously, "I wonder how long someone would have to hang upside down from a tree before turning into human jerky?"

 

Dead silence was replaced by laughter that sounded like spring ice breaking up on the Yukon River. Everyone took a deep breath. Dual though they might be, my preexisting relationships with these folk clearly carried some serendipity.

Gary, radiating misery, told how he'd initiated the affair with Susan. He looked beseechingly at Flora, who, rigid with hurt and anger, looked through him. "You betrayed me, Gary," she whispered. He nodded. She started to rise and for a moment I was sure she was going to bolt. It was then that I realized what I had at stake: I had gone out on a limb by not insisting that Gary seek counseling in Whitehorse and I was responsible for what came from that decision. I was afraid my entire therapeutic intervention was about to implode.

Then Burl admitted his plan to "damage" Gary--and made it clear that he'd been quite serious "at the time." Sitting back down, Flora said she almost wished he'd gone through with it, then broke into tears. What about right now, Gary asked? Where do we stand now? "I love ya, man," Burl blurted. "That's how I stand now." Telling Burl he'd been talking to Flora, Gary went over and tentatively sat down beside his wife.

Embarrassed, Burl glanced at Susan. She took a deep breath, then allowed as how he and Gary went back almost 40 years--were closer than most brothers--while she and Burl had been together not quite 8. She'd sometimes felt as if Burl was cheating on her with Gary! Flora managed a smile, then said without irony, "Hey, we're family, the four of us. Whatever's led to this, we can work it out." She glanced at Gary. "At least I want to."

That night, Denise said, "Well, are they all getting divorces? Is Burl really going to hang Gary from the top of a cedar and leave him to turn into jerky? Is Flora moving back to Toronto?" She kissed me goodnight. "The phone didn't stop all evening. Naturally, I had to pretend I knew absolutely nothing at all. And, of course, no one believed me. People simply can't fathom how you can keep all that good stuff to yourself . . . . You know, keep it from your wife, at least."

 

Too-close friends and erstwhile lovers, their lives intertwined on so many levels, Gary, Susan, Burl and Flora struggled to disentangle and disengage, not really knowing where the process would lead but determined to see it through. Everyone in Mile 666 cheered them on each step of the way.

I saw the four of them in every conceivable combination, including one session with Gary and Susan. Flora went "south" to visit family and after a couple of months, invited Gary to join her. He did, leaving Burl to run the logging show. Susan quit the Grubstake Grocery, asked me for six post-dated rent checks and then went off into the bush with Burl.

In Mile 666, I discovered there were precious few real secrets--an understanding that made it easier for me to keep what I knew to myself. After all, keeping "secrets" isn't all that hard when everyone else knows them.  Â

Jan Michael Sherman, M.A., is a marriage and family therapist who now lives on British Columbia's Sunshine Coast. He is in private practice, specializing in narrative therapy. Address: 9207 Truman Road, Halfmoon Bay, B.C., Canada VON 1Y2.. E-mails to the author may be sent to Michael_Sherman@sunshine.net. Letters to the Editor about this article may be sent to Letters@psychnetworker.org..

Friday, 02 January 2009 11:07

A Triple Boundary Crossing

Written by

 

 

A Triple Boundary Crossing

From Client to Friend to Client

by Arnold Lazarus

Therapists are expected, of course, to treat all clients with respect, dignity and consideration, and to adhere to the spoken and unspoken rules that make up our established standards of care. Many of these rules are necessary and sensible, but I believe that some elements of our ethical codes have become so needlessly stringent and rigid that they can undermine effective therapy. Take, for example, the almost universal taboo on "dual relationships," which discourages any connection outside the "boundaries" of the therapeutic relationship, such as lunching, socializing, bartering, errand-running or playing tennis. Naturally, sexual conduct falls into this forbidden category, and so do relationships involving conflicts of interest, such as a professors' serving as therapists to their own students.

But the blanket disapproval of "dual relationships" in some circles draws no distinction between "boundary violations," which can harm a client, and "boundary crossings," which produce no harm and may even enhance the therapeutic connection. For example, what would be so appalling if a therapist said to a client whom he has just seen from 11 a.m. until noon: "We seem to be onto something important. Should we go and pick up some sandwiches at the local deli, eat them here and continue until 1 at no extra fee to you?"

During the past 40 years, I have seen thousands of clients and have deliberately engaged in "dual relationships" with no more than 50. I have asked a client to drop off a package at a store that was not out of his way, engaged in barter with an auto mechanic who tuned my car in exchange for three therapy sessions and have gone to social functions and played tennis with some clients. Of course, I do not engage in such behaviors capriciously. Roles and expectations must be clear. Possible power differentials must be kept in mind. For my own protection as well as the client's, I don't chance things like this with seriously disturbed people, especially those who are hostile, paranoid, aggressive or manipulative.

But in our profession's antiseptic obsession with "risk management," there has been too little public discussion of whether the blanket rejection of dual relationships isn't, at least in some cases, needlessly constraining and perhaps even countertherapeutic. The following case is offered not as a blueprint or a path all therapists should follow, but as an unapologetic account of how and why I ignored a number of taboos. It is offered with the expectation that it will give many readers pause, perhaps even shock some, but also open up discussion of some long-neglected ethical issues in our field.

 

Mark and Sally

About 20 years ago, a depressed, 56-year-old man named Mark came to see me, accompanied by his bright, vivacious, 47-year-old wife, Sally, who was quick to tell me that she had majored in psychology in college and considered herself "a bit of a psychologist."

Mark, it turned out, was a successful corporate vice-president who had suffered several bouts of depression. I liked him almost immediately. His intelligence, humor, charisma and even-tempered style (which had helped him to advance to a high professional level) shone through his current low mood. He told me that despite his business success, his lack of self-confidence had caused him considerable distress, and he was often criticized at work for being too tactful, too diplomatic and too much of a peacemaker. His CEO, he told me, had recently said to him, "Mark, I just wish you'd occasionally bang some heads together."

We covered a lot of territory in that first session. Mark and Sally told me about their respective family backgrounds and the somewhat strained relationship between Mark and Samantha, Sally's 9-year-old daughter from a previous marriage. We discussed situations in which Mark was apt to feel anxious and unconfident. When the hour was up, Sally turned to me and said; "If you could help Mark become less passive, I think this will be extremely beneficial."

I met with Mark alone after that, and once I had administered a battery of psychological tests and seen him for a couple of sessions, it was clear to me that his depressive episodes occurred when he overreacted to disappointments. Sally was correct in calling him too passive: he went out of his way to avoid confrontation, a trait that he attributed to a family upbringing that placed a high value on the old Biblical adage "Turn the other cheek."

 

A large part of our therapy consisted of role-plays, and for weeks Mark rehearsed assertive responses to various situations. At work, for example, he thought the accounting firm his company employed was inefficient and careless. Their lateness often resulted in needless bank penalties and irritated customers. Yet, he didn't want to make waves.

I pointed out that avoidance set him up for depression, especially when other irritations piled up. So, he and I rehearsed dialogues he might have with the company's chief financial officer, and I then encouraged him to act on them. I remember telling him, "You need to get rid of that 'Turn the other cheek' philosophy and replace it with TNC--Take No Crap!" After considerable hesitation and trepidation, he urged the company's top executive officers to fire the incompetent accounting firm, and his confidence and status within his company soared when a new group of accountants was brought in that performed far more effectively.

Over the months, Mark became more outspoken and learned to bounce back faster from disappointments (which were fewer), and his dark moods lifted. He proudly referred to this change as "testicular enhancement." Then, at the end of a session in which we discussed the need to schedule some final meetings to consolidate his gains, Mark said, out of the blue: "Would you and your wife be willing to come to our home for dinner some time?"

To this very day, I remember being struck by the fact that he had said, "to our home," rather than something like, "Would you come over for dinner?" I generally avoid mind reading, but I couldn't help feeling that he was really asking me something along the following lines: "After all I've told you about myself, do you trust me enough and regard me as worthy enough to enter my home with your wife and break bread with me?" This was not the first time I had received such a request. Other clients had extended social invitations of one kind or another, which I had accepted perhaps a dozen times in the past. With Mark, as in the other cases, I felt that to refuse his invitation would undermine the work we had done together. So I crossed the boundary and said that I'd very much like to accept.

 

At the dinner, Mark casually introduced me to the other guests as his "shrink." He and Sally were gracious hosts, the wine was excellent, as was the food, and the entire evening flowed effortlessly. My wife and Sally, who had never before met, struck up an instant friendship. Later, my wife and I talked about how comfortable the evening had been and agreed that Mark and Sally would enjoy meeting several of our other friends. So, in due course, we invited Mark and Sally to our home for dinner with two other couples. Again, we enjoyed ourselves immensely.

My wife and I soon found ourselves going out to dinner with Mark and Sally regularly, taking in movies, lectures and Broadway plays, playing tennis and even taking vacations together to Canada and the Caribbean. It turned out that Sally and my wife had many interests in common; they went to flower shows, art galleries, joined a women's discussion group and attended cooking classes.

Over the next several years, Mark became one of my closest friends and my wife and I saw him and Sally several times a month. When he and Sally began seeing a marriage counselor, he confided the news to me as one would to a good friend. But then, several months later, Mark called to tell me that they were unhappy with their counselor and asked if I would see Sally and him professionally. I said I'd really rather keep our relationship purely social and recommended several good therapists. When they insisted, I told them that seeing friends in therapy ran counter to the ethical codes of my profession and I could land in hot water. Mark, who apparently had learned his lessons well about speaking up for himself, quickly challenged my initial reluctance saying, "Coming from you, that sounds ridiculous. Since when do you bow to needless authority?" That took me aback.

I wrestled with the question of what to do for three or four days, discussed it with my wife and several colleagues and only acquiesced when a number of people convinced me that, with all my knowledge of both Mark and Sally and my comfort with our relationship, I was in a unique position to be helpful to them.


Some Sticky Situations

Initially when we started working together, I found myself ill at ease asking the sort of penetrating questions I would normally ask a couple, some of which would be regarded as inappropriate within the domain of friendship. But then, I began to feel something even more disconcerting. All the affection, caring and fond memories that I had for Mark and Sally as friends were there, but as I focused with them on the difficulties in their connection to each other, it became clear that there was no strong underlying attachment between them. There were simply too many unresolvable resentments (especially Mark's unhappiness at the way Sally's intense bond with her demanding teenage daughter overshadowed her relationship with him and her unwillingness to try to change that balance in any way). They both admitted feeling less put upon when not in each other's company, and all attempts to resuscitate the vitality of their marriage--in-session coaching, homework assignments, improving communication skills--went nowhere. Yet, I felt that they each expected me to conjure up some magic that would infuse deep love and passion into their relationship.

At this point, I regretted that I had allowed myself to be talked into treating Mark and Sally. I felt a lot of pressure from the demands of having been their therapist, then becoming very close friends and again engaging in formal therapy with them. I could feel the pull of the implicit wishes and expectations that I simply could not fulfill. But I was too deeply committed and involved to back out.

It's one thing to tell the average client couple that their marriage seems to be dead, but it's far harder to advise friends to split up. I felt bad about letting Sally and Mark down, for failing to possess the magic wand that would transform their shaky relationship into a solid and satisfying marriage. Nevertheless, I gave them my professional opinion. They both thanked me for my candor. Even so, I felt uncomfortable and feared that it might spell the end of the friendship.

An amicable divorce followed. Mark bought a house, and Sally helped him furnish and decorate it. The four of us continued to play tennis and go out together. I was surprised and relieved at how easy it was to let go of the therapist role and become just a friend again. I was very pleased that the friendship had not been damaged. One evening, when my wife and I were driving home with Mark and Sally from New York, Mark whispered to me that he could take Sally in very small doses and that he was absolutely delighted that he would be dropping her off and then going on to his own home.

 

Sally and my wife have continued to be friendly, but the primary bond has always been between Mark and me. Mark remarried and his new wife also got on very well with us, and our friendship with them continued until they moved to California 4 years ago. It is now about 14 years since the therapy terminated. Mark and I still speak on the phone occasionally and often send e-mails to each other, but I still wish he lived close by.

While boundary crossings can have salutary effects, one should never underestimate the emotional complexities to be sorted out and, sometimes, the toll to be paid. Since my experience with Mark and Sally, I have entered into only one other triple boundary crossing (i.e., therapist--friend--therapist) and I will not venture into that territory again--it's just too demanding emotionally. Nevertheless, I continue to find that occasional extratherapeutic contacts with selected clients can enrich their lives and expedite our work together. After all my years in this field, it is clear to me that self-protectively distant or defensive therapists are more likely to injure than to help their clients. We must all be sure that mere risk management does not become more important than making our very best effort to serve our clients.


Arnold A. Lazarus, Ph.D., ABPP, is a distinguished professor emeritus of psychology at Rutgers University and has a private practice in Princeton, New Jersey. He is the author of many books, including The 60-Second Shrink (coauthored with his son, Clifford Lazarus), Marital Myths Revisisted and the forthcoming Dual Relationships and Psychotherapy (coedited with Ofer Zur). Address: 56 Herrontown Circle, Princeton, NJ 08540. E-mails to the author may be sent to AALaz@aol.com. Letters to the Editor about this article may be sent to Letters@psychnetworker.org.

 

Friday, 02 January 2009 11:06

Love, Dr. Lagerfeld

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Love, Dr. Lagerfeld

Sometimes It's Okay to Trust Your Instincts

by Michael Hoyt

We therapists tend to worry a lot about boundaries, sometimes to the point that we forget that sharing our humanity can be a gift, not a distortion. Most of us have sometime or other been moved to share a personal experience, or quote a famous Zen story or Bible passage or maybe simply laugh or cry with a patient. We're connected and in sync. But when is it okay to go with our impulse and when is it wiser to hold back? And how helpful are all our therapeutic models in helping us decide? I remember sitting in a seminar 20 years ago with Erik Erikson listening to a therapist go into a convoluted analysis of the transference-countertransference dynamics of one of his cases. Finally, Erikson interrupted the theoretical discussion to ask, "Have you ever thought that maybe it's just reality?"

Consider the case of Bill and Maria, a Portuguese American, working-class, Catholic couple in their late fifties with whom I worked for several years. I initially met Maria, who sold cosmetics at a local department store, when she came to our HMO clinic distraught and depressed by the recent and tragic death of her son, who had died at the age of 20 under ambiguous circumstances. (His gun had somehow discharged while he was alone at a hunting cabin.) Maria was grieving terribly, of course, and kept questioning whether the death had been a suicide and what she could have done to prevent the tragedy. This was a natural human response, but Maria added, "I'm always feeling responsible and taking care of everyone. It's just the way I am."

Her husband, Bill, soon came in as well. He was a good guy--a truck driver, outgoing, friendly and a bit gruff in his way. "Doc, don't misunderstand me--Maria and I are both hurting real bad. But this is destroying us. We've got to find a way to go forward."

A couple of weeks later, Maria presented me with a gift--she had recognized a cologne I was wearing, called Lagerfeld, and brought me a large, expensive bottle. It seemed (to me) unnecessary and a bit excessive, and clearly fit her pattern of compulsive caregiving; but when I hesitated to accept it, she looked hurt. Bill insisted ("Come on, Doc"), and I felt uncomfortably ungracious. I finally accepted the gift, thanked them and we continued talking.

 

I had received occasional presents from other patients, of course--chocolates and homemade cookies at Christmas, or a small "forget-me-not" token of appreciation (such as a favorite book) at the end of a therapy. The gift from Maria seemed somehow different. Several times, she offered to bring me more cologne, and while she seemed okay with my "Thanks, but no thanks," I noticed that I would usually wear the cologne on the days when Bill and Maria were scheduled to come in.

I could almost hear the clucking disapproval of my internalized psychoanalytically-oriented colleagues ("Acting out!" "Countertransference!"). As I struggled to sort out my feelings, I found myself thinking about the cultural anthropology of gifts, of reciprocity and exchange and potlatch, as well as Kahlil Gilbran's lines from The Prophet about the grace of giving and receiving. I also recalled an old supervisor's discussing with me his once declining an expensive gift (a Mercedes automobile) from a very rich client. The patient had argued that the cost was inconsequential, given his wealth, but my supervisor had declined, he said, ultimately because the cost would have not been inconsequential to him--accepting it would have made him feel too obligated.

Over time, Bill and Maria consulted me about a variety of problems, some having to do with their grief, some with their marriage, some with dealing with other family relationships. The death of their oldest son was sometimes in the foreground, while at other times it receded, yet, still casting a long shadow. Life moved forward, slowly.

After many months, during a session, Bill and Maria told me about an uncanny experience. They had finally gone for a little vacation to Las Vegas, their first time away together since their son's death. It had been a good experience, but what had really gripped them was something that happened on their last night there. They were in a lounge and they both saw a young man who looked startlingly like their son. They knew it was not, but the resemblance was amazing. He was at a nearby table with some friends, laughing. Bill and Maria were mesmerized--they could not stop looking at him and, eventually, they even called over the waiter and sent an anonymous bottle of champagne to the table to keep the young party there so that they could watch longer. From their poignant description in my office, the experience had been magical and wonderfully bittersweet.

 

A year or more later, as our meetings continued, Bill and Maria came to see me in the midst of a very rough patch. They had gone through another anniversary of their son's death and were not getting along. Bill was having problems at work and Maria had been reaching out to a daughter who lived out of state and was distressed when her many phone messages went unanswered. They bickered and argued, Maria complaining that Bill wasn't really sympathetic, and Bill complaining that he felt neglected. "Of course, I care," he said, "but I'm getting awful tired." Their marriage appeared to be in trouble, but near the end of the hour, Bill mentioned that they were going out to dinner the next night, to the local Black Angus Restaurant, for their wedding anniversary.

After they left my office, I had an urge. It was not so much that I had to think of it--it was suddenly there, and felt right. I sat for a few minutes, musing, then smiled as I thought of my old mentor, Carl Whitaker, who had often encouraged me to listen to my heart and trust my instincts.

I saw my next patient, then got ready to leave. I picked up the telephone, called Information and got the address of the Black Angus. I drove over and explained to the maitre d' that some friends of mine were coming to dinner the next night and that I wanted to leave a present for them. I paid for a bottle of champagne and wrote out a brief note to accompany it: "Happy Anniversary! Love, Dr. Lagerfeld."

 On the way home, I knew I had just done something unusual. I rushed into the house and told my wife about it: the couple, the kid in Las Vegas, the champagne, Dr. Lagerfeld and the cologne. "What will this do to the therapy? Should I call the restaurant and cancel my order? Will it make it so they can't express anger toward me? Am I invading their privacy?" I was very nervous. My wife looked at me and then said, "Honey, that's probably the nicest thing you've ever done!"

I did not call the restaurant.

 

A week went by. The following Thursday, Bill and Maria arrived for their appointment. We sat down in my office. I looked at them--first Maria, then Bill. Suddenly, Bill smiled. "Doc, I got to tell you, I don't usually let myself get too emotional, but what you did last week made me want to cry. Nobody's ever done anything like that for us. At first, when the waiter came to the table with the champagne, I thought it must be a mistake. Maria and I really enjoyed it, and I sat there and every time I looked at that champagne bottle and at Maria, I thought about how much we've been through and how much I love her. I don't know what else to say. Just, I really want to thank you."

This did not resolve all their problems, of course, and the work went on. I'd like to think my gesture--and the abiding feeling it signified--may have helped them weather the storm. Was it countertransference? Transference? Reality? Love? Maybe it was just me--and them.Â


Michael F. Hoyt, Ph.D., is a senior staff psychologist at the Kaiser Permanente Medical Center in San Rafael, California. His most recent books are Some Stories Are Better than Others and Interviews with Brief Therapy Experts . Portions of this article originally appeared in M.F. Hoyt, "Connection: The Double-Edged Gift of Presence," Journal of Clinical Psychology: In Session 57, no. 8 (2001):1-8. ©2001 John Wiley & Sons, Inc. Reprinted by permission. Address: Kaiser Permanente Medical Center, Department of Psychiatry, 820 Las Gallinas Avenue, San Rafael, CA 94903. E-mails to the author may be sent to Michael.Hoyt@KP.org. Letters to the Editor about this article may be sent to Letters@psychnetworker.org.

 

Friday, 02 January 2009 11:05

The Necklace

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The Necklace

When Does a Rule Become a Straightjacket

by Jenny Newsome

When I was young and only three years out of graduate school, one of my first private clients came into a session carrying a small package simply wrapped in brown paper and string. The memory of that package and how I reacted to it haunts me still.

The client--Katy--was a businesswoman who had come to me six months earlier, dumbfounded by a depression so deep that she was fighting the impulse to drive her car off a bridge. In cognitive-behavioral therapy, she'd improved steadily, returning to activities she had previously enjoyed and finding the strength to let go of unfixable situations she'd badly wanted to fix.

She was dressing more casually, laughing easily and entertaining ways to broaden her already full life. She'd decided to leave her present employer, expand her private consulting business and enroll in a Ph.D. program. Even though her depression was resolved, she had continued in therapy in order to solidify her changes and stay in touch with her long-term goals. All in all, I couldn't have been more pleased about the progress of her therapy.

Then came the fall day when, much to my surprise and horror, Katy came into her session and gave me the little brown-paper package. I unwrapped it and found a small, black velvet box. Inside, was a necklace, and not just any necklace: a gold chain with a diamond pendant that she had designed herself, worth about $500.

I took a breath. I was out of my depth.

 

Katy knew that giving a gift to one's psychologist could be tricky, so she was also armed with a persuasive list of reasons why I should not refuse her gift. She told me earnestly that it gave her great joy to thank me in a special way. Given her high income, the necklace was comparable to a holiday box of chocolates from a middle-class patient she insisted. She wanted to celebrate her therapy success, and this was a way of making it tangible. The choice of a diamond held great significance: it was analogous to her experience of the transformative power of therapy. The earth, she explained, takes a dark substance (carbon) and subjects it to great pressures that make it clearer and better than it was before.

Being young and new and the good ethical psychologist that I was trained to be, I did just what she feared: I refused her gift. I thanked her for the thought and said it was against my professional code of ethics to accept.

Katy looked pale and shaken and said she felt dizzy. I had to suggest she take some deep breaths. I tried other cognitive-behavioral strategies, but this was not a simple panic attack.

I asked her if this was a transference issue in which she was confusing aspects of our relationship with other significant people and events from her past? No. Was she trying to bribe me into having a non-therapy relationship? No again. Did she have trouble receiving help without reciprocating? She said that although she liked to reciprocate kindnesses, she did not feel "driven" to do so.

Then she told me she felt insulted that ethical rules designed to protect vulnerable patients were being applied to her, even though her depression was in remission. Would she now always be classified in such a way that her own judgment could be questioned? Didn't I trust her to make good decisions? And isn't a cigar sometimes just a cigar?

 

Finally, terrified and exhausted, I told her flatly that accepting something so expensive was against the ethical rules of my profession and I did not want to place myself at legal risk. Katy got so upset that, again, I thought she might faint. I agreed to hold onto the necklace for 10 days and talk about it again at our next session.

I put the black velvet box in my desk drawer.

Meanwhile, I talked to close colleagues, called the American Psychological Association ethics board, my state ethics board and a lawyer-psychologist who specialized in ethics law. I took the train to Philadelphia and New York to consult with two of my mentors, one of whom had supervised me in graduate school. (In the end, I spent more money on consultations than the dollar value of the necklace.)

My mentors told me I was running the risk of dehumanizing Katy and jeopardizing our therapy relationship by being so scared and rigid. The ethics boards and lawyer both told me that it was in Katy's interest that I accept her gift.

But that was not the reaction I got closer to home. One of my closest colleagues suggested that Katy must be a "borderline" and secretly in love with me. Another recommended I accept the gift but never talk about it.

 

With much anguish, after 10 days, I accepted the necklace, thanked Katy and brought the black velvet box home. Katy and I continued therapy for several more months before terminating, but something had changed. The sense of a "dirty little secret" had leaked into our sessions.

I had consulted with everybody I could think of and tried to please them all. Losing touch with my own best instincts, I'd gotten enmeshed in our profession's confusion over how to respond to a client's gratitude while safeguarding her from exploitation. In the process, the beautiful necklace Katy had given me had become tainted--not the celebration of growth and gratitude she had meant it to be. I'd allowed other voices into the sanctuary of our therapy and once they were there, I couldn't get them out.


"Jenny Newsome" is the pseudonym of an experienced cognitive-behavioral therapist on the Eastern Seaboard. Letters to the Editor about this article may be sent to Letters@psychnetworker.org.

 

Friday, 02 January 2009 11:04

The Crush

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The Crush

Challenging Our Culture of Avoidance

by Mary Jo Barrett

Before it happened to me, I had never heard even my closest colleague talk about falling in love with a client. In our consultation group, the subject was once broached purely theoretically, and everyone became uncomfortably quiet. Nobody shared a personal experience. The message we gave each other was clear: Whatever you do, don't talk about having a crush on a client! And that may be why I would rather write about being seen naked by a client at the health club, or dealing with anti-Semitic remarks in session, than describe to you what happened.

Yet, I want to break our conspiracy of silence so that we can get help when we need it. And believe me, when it came to Scott, I did.

Scott was 34 years old when he was referred to my therapy center by the courts. He had nearly strangled a truck loader who had made a major mistake at his metals manufacturing company, and in previous years, police had been called on three different occasions by girlfriends he'd struck in late-night arguments. He had never been in therapy before he saw me. Unmarried, childless and an amateur jazz musician, he worked hard by day and hung out with famous and creative people at night. He was gorgeous, at least to my taste: tall, well-built and (like many men with a history of violence) charming, intelligent and a champion at forming relationships.

Although I had spent years working with violent offenders like Scott, from the beginning, I wasn't sure I would be a match for him. I was 44, tired, working long hours and steadily gaining weight. My father had just died and my mother was ill. I could still remember when I thought my husband, Dennis, was the most perfect person in the entire universe for me, but we were now slogging through mid-life, staying home on school nights and getting our three kids to school each weekday morning. We hadn't had even a weekend alone together in years, because I felt guilty about the time I spent away from the kids while traveling for work. There were no obvious conflicts between Dennis and me, but things were flat.

 


Bemused, Bothered and Bewildered

In my initial work with Scott, I could see that he was uncomfortable to be in a relationship in which he was not totally in control--a familiar early stage of therapy, when clients and I are working out our power balance. Usually, I quickly get a feel for how to establish a collaborative relationship where I am, nevertheless, in charge. Not with Scott.

I was flirting instead of guiding. Conversing instead of teaching. Worrying about my feelings instead of his. Confused rather than clear and purposeful. Thinking about him outside of sessions. Giddy and confused.

I always dress modestly in pants when I work with offenders, but on Scott's days, I wanted to look hip and stylish and young. I felt like a schoolgirl.

In session, he worked hard to please me and often told me what a fabulous therapist I was. I'd heard it all before, but this time, I did not use a client's compliments as therapeutic material; I simply let them wash over me. He smiled. He left long messages on my voicemail, telling me funny stories, small successes, struggles and new behaviors that would make me proud. I was amused by his stories of life with the rich and famous. I loved participating vicariously in his exciting life, and I was flattered that he kept me emotionally present even when we were apart.

From the outside, our sessions may not have looked much different from hundreds of others I've conducted, but I knew they felt different. Instead of keeping him engaged in the process, I was working hard to keep him engaged in our relationship. I wondered if he was changing at work, treating his employees better and becoming a better human being. He had become my personal project. Singlehandedly, I was going to turn this man around and help him become a mench, a human being with a good heart and soul. When he said he'd prefer to do his hypnosis lying on the floor--and then asked me to sit on the floor next to him--I said no almost too forcefully, totally flustered.

 

This was not the Mary Jo I knew.

The worst part was the terrible isolation I felt. I pride myself on being clear during therapy and on top of my game. When I am not, I usually go immediately for help to get me back on track. Not this time. For two months, embarrassed and ashamed, I struggled internally and alone. I didn't tell Dennis, or anyone else.


In Consultation

Finally, from the office late one night, I called my best friend, Linda, a therapist who lives safely 1,000 miles away. She reassured me that what was happening between Scott and me happens to many of our peers. We talked about the fact that the only scenarios we had heard were the horror stories--where crushes turn into affairs followed by personal and professional disaster.

Once I began to talk openly about my feelings, I realized that danger existed only if I behaved unethically. As Jimmy Carter taught us, many of us have lust in our hearts. The danger lies in not understanding the lust and not taking responsibility for how we behave in response to it. I was clear on my marital and professional responsibilities. I was not about to act out my crush.

Nevertheless, I also realized that I had to bring my dirty secret out of the closet, understand it in context and commit to a plan of action. And I ­couldn't do that just through a phone call with a best friend 1,000 miles away.

And so, I finally brought up my Scott crush in my consultation group. We began to explore my feelings and some of the group pushed me hard to question whether I should terminate and refer him out. "What is he bringing up in you?" they asked. "What's getting stirred?" It soon became clear that Scott had arrived just in time to smack head-on into my own mid-life development crisis.

 

I felt like a middle-aged, boring mother getting through each day. With his jazz-playing, freedom and fascinating friends, Scott reminded me of my own carefree younger days, when I'd first fallen in love with Dennis (he was my landlord and I'd met him when he came over to install a fire extinguisher). Dennis made me feel special then--he read everything I wrote, told me I was brilliant and came to my speeches. We hiked and lifted weights together, went out for dinner and stayed up talking long into the night. There was no such thing as a school night. Scott had stirred up a longing for those days. He even looked like Dennis.

I told Dennis about what had been going on. We started working out together again and taking walks without the kids. We went away together and spent a wonderful weekend in New Orleans shortly before Mardi Gras, when Dennis flew in to meet me after I'd finished a training.

Meanwhile, my consultation group helped me role-play less flustered responses to Scott's flirtatiousness. They pushed me to ask him whether he was making changes for me or for him?

Over the course of the weeks, I stopped feeling like a deer frozen in the headlights. I began working with Scott with an easier mix of head and heart. Our consultation group also changed: we began taking greater risks with one another and the therapy we did subsequently improved. We commented on the new level of intimacy we had reached together.

 

And I stopped feeling like a schoolgirl on the day of Scott's sessions.

Scott finished therapy six months later without ever having known about my crush. Two years later, he asked to come in for some brief couples work with his new partner, whom he was thinking of marrying. Given my history, I decided to refer him out; he signed a release and went to a colleague I recommended. A week later, as I was catching her up on his history, I said over the phone, "You will really enjoying working with him. He is very committed and desires to change. Plus he is so adorable."

She said, " Oh, I don't think he is cute at all. Definitely not my type."


Mary Jo Barrett, M.S.W., is the director of the Center for Contextual Change in Skokie, Illinois, specializing in the treatment of violence and its aftermath. She is the coauthor of Treating Incest and The Systemic Treatment of Incest . Address: Center for Contextual Change, 9239 Gross Point, Skokie, IL 60077 E-mails to the author may be sent to Mjb.ccc@att.net. Letters to the Editor about this article may be sent to Letters@psychnetworker.org.

 

Friday, 02 January 2009 11:04

The Slippery Slope

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The Slippery Slope

Violating the Ultimate Therapeutic Taboo

by Susan Rowan

I doubt that I would fit many people's image of a therapist who would violate sexual boundaries with a client. Before it happened, I certainly did not fit my own. On the day I first met Cara, I was a well-respected social worker at a venerable psychiatric hospital in the Midwest. I viewed myself as a caring and conscientious professional. Yet, over the course of two years, I progressed from sympathizing with Cara, to over-sympathizing with her, buying her groceries, paying her rent and, finally, sleeping with her. At first, I did not think I was doing anything harmful--I was going the extra mile, helping Cara until she could take care of herself. But my previous dedication to all my clients became an obsession with one.

It was as though I were skiing down a steep mountain in what seemed to be deep, safe snow. Blinded by arrogance, I traversed back and forth, each time taking a little more risk. There were unknown moguls under the surface and, as my speed picked up, I totally lost control of my skis.


Starting Down the Slope

Therapy began routinely enough in the summer of 1993. Cara, the attractive mother of young, twin boys, had been hospitalized following the latest in a series of suicide attempts and self-mutilations. She and her husband were assigned to me during her hospitalization for marital therapy. Despite her troubles, I found her to be bright, sensitive and a talented visual artist. Subjected to severe physical abuse as a child, Cara had been given the diagnosis of Dissociative Identity Disorder, and her childlike alter-personalities and novel diagnosis intrigued me. I extended our meeting times in preparation for her marital sessions and took long walks with her on the hospital grounds. Overwhelmed by feelings of protectiveness, I doubted the competence of hospital staff to prevent her ingenious attempts to harm herself.

 

After four months of marital therapy, Cara's husband discovered she had had an affair before her hospitalization and, at his insistence, their marriage ended. Soon afterward, Cara was discharged. My job was now officially over: it required me only to provide short-term family therapy until a patient's discharge. But then, Cara called me at my hospital office a week later to discuss a personal problem, and in one of my first major boundary slips, I took her call.

Why did I encourage this first, seemingly minor, deviation from good clinical practice? I was vulnerable, ignorant, arrogant and lonely. I'd recently ended a 10-year relationship with another woman--a relationship so intimate that we'd both worn wedding bands. Depressed, numb and disconnected, I was drinking alone at night. My work provided me with my only emotional sustenance, and it, too, had become a dark and confusing place. It was the early 1990s, and our inpatient unit was fast becoming a world of its own--we were fascinated with childhood trauma and Multiple Personality Disorder, and convinced that other clinicians did not understand these clients. I spent many daylight hours listening to patients describe horrifying abuse, and at night I had nightmares of young children who were being sodomized.

At the same time, I was becoming isolated from the norms of my profession: I left my family therapy supervisor and began working under a charismatic psychiatrist who specialized in trauma. As a family therapist and a social worker, I'd been taught to pooh-pooh psychodynamic notions like transference and countertransference. I had never even taken a course in professional ethics or the need for boundaries. Over dinner one night, my new supervisor confessed to me that he was having an affair with one of his clients, and told me of the many founders of psychoanalysis (including Carl Jung, Otto Rank, Frieda Fromm-Reichmann, Fritz Perls and Sa´ndor Ferenczi) who had also had such affairs. The stage was set for me to do so as well.

Not long afterward, I gave Cara my beeper number, and within a couple of months, we were talking on the phone almost daily. I rationalized we were becoming friends. It was an odd sort of friendship.

 

One day, she called me in distress, saying she had no money to feed her sons. I called the department of social services on her behalf, rationalizing that I was merely being her advocate. A month later, after an alarming, drugged-sounding call from her, I drove to her home and found her lying in a pool of blood, having severely cut herself. I called the ambulance and stayed behind to clean up her blood, hoping to protect her young twins from trauma when they returned home from daycare.

Again, I ignored my violations of clinical boundaries--boundaries as much for my own protection as for hers. I was skiing out of control. A few weeks later, Cara asked me for money for groceries. Uncomfortable with giving her money, I took a shopping list from her, went to her house with five full shopping bags and helped her stack her shelves and refrigerator, gratified by her effusive thanks. Next, she asked for rent money, and then for help with her gas and electric bill. I paid them both, and she told me she didn't know what she'd do without me.

Why on earth did I do it? I've spent years since then examining the risk factors that led me to destroy my professional career. Part of the explanation lies in personal vulnerabilities my previous training never encouraged me to explore. (I had never been in therapy myself.) My own mother had been seriously ill with rheumatic heart disease throughout my childhood, and had died when I was 18. A sister 20 years older than I had been my surrogate mother and had paid for my college and graduate school. As I stacked Cara's groceries that day, I rationalized that I was helping her and her children--as my sister had helped me--just until she could function on her own. I was dead wrong.

As my financial support increased, Cara put more and more effort into getting my help, and had less and less into working on her own behalf. She reinforced my behavior by sending me beautiful pictures she had drawn. We exchanged letters, discussing our most intimate thoughts about society, people and relationships. We lunched, played tennis, even took an art class together. Just before her twins began kindergarten, I helped her to find a new apartment in a better school district and paid the increased rent. Instead of developing confidence in her ability to run her own life, she was developing a pathological dependence on me.

 

I found myself more and more attracted to her. She had a pleasing way of interacting with others and could be, in some ways, seductive. Sometimes, after drinking heavily, I made clumsy attempts to tell her that I thought I was falling in love with her. Several times, we kissed each other, and one evening we went into her bedroom together and lay close with our clothes on.

Over the next month, we had a few tentative sexual encounters. After each one, I felt disgusted and upset with myself. (Far gone as I was, I knew it was not okay to sleep with clients, former or otherwise.) One night, I told her my feelings. She responded sensitively and empathically. We agreed to remain friends but to stop being physically intimate.

That did not mean the end of our mutually dependent and increasingly destructive relationship. Just because I was drawing back, Cara did not magically develop the autonomy and self-confidence she had originally sought through therapy. I drove her to difficult therapy sessions and babysat her twins when she was away. What had begun as a request for a few hundred dollars mushroomed into demands that totaled $40,000 before the end of our relationship.

As she became more desperate and demanding, I became more miserable. I stopped returning her increasingly angry phone calls. She finally left a message on my answering machine telling me that she could ruin me.

 

Finally, depressed and on the edge of financial collapse, I told her that I was going to end all contact and financial support on a set date two months hence. When the date came, she was back in the hospital and reported our sexual relationship to the hospital authorities. When they asked me, I told the truth. I could not fight anymore.

I lost my job. My clinical reputation was destroyed and my license was revoked for two years pending rehabilitation. Cara sued me and I had to declare bankruptcy. I lost a promising career spanning more than 20 years, as well as the respect of many friends at my beloved hospital.

Retooling

Since that day seven years ago, I have been fortunate enough to be allowed to return to practice. I passed a forensic evaluation and my licensing board has reinstated me, under strict conditions that include having a mentor (a specialist in transference and countertransference) to oversee my clinical work. I've undergone prolonged retraining, including an individual ethics tutorial. I've studied the professional literature on ethics violations and have been educated in the need for boundaries. The lawsuit was settled by my insurance carrier and I stopped drinking. As a condition of my license reinstatement, I am required to undergo psychotherapy until my therapist and I feel I don't need to any longer--at least another two or three years.

I realize that some therapists reading this may feel sympathetic toward me--that I tangled naively with the sort of boundary-less client that we're frequently warned against. But the responsibility lies with me. It was my responsibility, not hers, to know my profession's norms and to preserve clinical boundaries. It was my responsibility to understand that power between a client and a therapist is never equal and that a so-called friendship is never appropriate after clinical work. It doesn't matter how provocative, vulnerable or seductive a client is. It is my responsibility not to create pathological dependencies.

 

I still find it difficult to reconcile the fact that I was so destructive to Cara's life, when I intended to be so helpful. Yet, morally, I am left with the consequences of my actions. After our relationship, Cara continued to cut herself and had even less confidence in herself and in the possibility that our profession could help her. I do not believe there can be a harsher critic of me than I am.

I work now in a community mental health clinic at about half the pay I used to receive. Every day, I try to be aware of any sign that I could be taking a first step down that slippery slope. Recently, on a windy day, a poor client asked me for busfare home. It seemed like a simple request, one that I could easily honor. I said no.

"Susan Rowan" is the pseudonym of an experienced licensed clinical social worker in her mid-forties. She works with the severely mentally ill in a community mental health center.

 

Red Flags Signaling Loss of Control

I have chosen to write my story, in part, so that others could learn from my mistakes. I hope I have learned from them. I will forever be aware of the warning signs that signal a loss of control. Below is a list of "red flags," distilled from the clinical literature and my own experience, that I hope will help other therapists stay off the slippery slope.

- Specialness . A belief that this particular client, therapist or situation is somehow "special" and the ordinary rules don't apply.

- Attraction. Intense attraction of any kind, including: fascination with a particular diagnosis; excessive time worrying about the client; sexual, romantic or rescue fantasies; excessive pity or admiration.

- In-Session Behavior Changes. Spending more time together than is clinically appropriate. Excessive self-disclosure and poor impulse control by the therapist. Being unable to say no to the client.

- Violating Clinical Norms. Changing normal routines: seeing a client outside the office; excessive gift-giving or receiving; giving money; reducing fees inappropriately.

- Professional Isolation. Neglecting outside interests. Professional and personal isolation. Concealing the situation from colleagues.

 

Friday, 02 January 2009 11:03

Nightmare in the Aisle

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Nightmare in Aisle 6

A Therapist Caught in the Act of Being Herself

by Linda Stone Fish

I live in a small city in Upstate New York, and most people in town know somebody who knows me, my husband (a clinical psychologist) or one of our four engaged and energetic sons. My husband and I are both active in our town's small Jewish community and have private practices; I teach family therapy at the local university; and all of our sons are heavily involved in athletics, drama and school social life. So it's no wonder that I sometimes cross paths with my clients in town--if not at the supermarket, then on the athletic field, at the hairdresser's or at temple.

Despite all this, I managed, for two decades, to maintain (in my own mind, at least) a fire wall between my personal and professional lives. In the consulting room and the classroom, I worked to present an air of calm worldliness, an expert with the answers to all sorts of painful therapeutic and family dilemmas. I was at pains not to look like someone who would lose it with her kids or yell or scream--which is precisely what I sometimes did when I got home to a house full of hungry boys ranging in age from 4 to 16.

Then, late one spring afternoon four years ago, I walked into Wegman's, the huge supermarket on the east side of Syracuse. (It's the kind of place with a dry cleaner and a cafe as well as acres of gorgeous fruits, breads and vegetables.) With me was my youngest son: 4 years old, tired and whiny. I'd been teaching and seeing clients all day. There was nothing in the house for dinner. I was having babysitter problems and I was due at another son's baseball game in less than an hour. In short, I was fried.

Near the yellow and red peppers, I pried a shopping cart loose and asked--or rather told--my son to get in. He refused. In no mood to fool around or cajole, I grabbed him by the shoulders, lifted him up and tried to force him into the cart. He stiffened and began screaming.

 

It was one of those moments when other shoppers look over and think, That is the worst mother in the world. That poor child! I wanted to yell at my son at the top of my lungs or just leave him screaming on the floor while I shopped, but instead I managed to bend his legs into the cart and wheel him forward, still screaming. I was picking up hamburger buns when, out of the corner of my eye, I saw Jan, one of my most recent clients. She was staring at me, and she wasn't the only one.

I did the only thing a professional could do under such circumstances--I pretended she did not exist, kept my eyes straight ahead and wheeled my screaming child toward the meat section while acting as though I was on a cruise drinking pina coladas.

Jan (now thankfully out of my sight) had become my client six weeks earlier because she was exhausted and overwhelmed by her 13-year-old daughter, who was doing poorly in school and behaving badly at home. We were at an impasse: Jan wanted me, the expert, to see her daughter individually and straighten everything out. I was insisting on seeing mother and daughter together and was (so far unsuccessfully) encouraging Jan to do homework that involved connecting with her daughter while setting limits.

Or at least, that was the role I was trying to play with Jan, until the moment she saw me push a screaming child around the supermarket in a controlled frenzy, picking up milk, hamburger, frozen french fries and a bag of lettuce greens. In the car on the way home, with my son still screaming, I, literally, had fantasies of closing my private practice and getting a job at K-Mart.

All that week, I waited for the call canceling Jan's next session and letting me know what a joke I was. But on Friday at 4:30, Jan appeared with her daughter Sarah to tell me that, for the first time, she (Jan) had done the homework I had given her. (I had asked her to stand up to her daughter and make sure she did a schoolwork assignment, even if Sarah tried to distract her by being mean.) Jan had also made an appointment with a school administrator to get an evaluation of her daughter's learning problems. Her passivity had disappeared.

 

"Linda, I hear what you have been saying," Jan said. "I needed to do something different and I was resisting it!"

"I'm so impressed!" I said, leaning happily back in my chair, figuring that the woman in the supermarket must have just been a Jan look-alike.

"Seeing you in the grocery store really had an impact on me," Jan said. "Boy, do you have your hands full!"

I reminded myself to breathe.

"You were a myth to me," Jan went on. "You had it all together. How could you understand how overwhelmed I felt? Then, I saw that you, too, are overwhelmed, but you just keep putting one foot in front of the other. I can't tell you how empowering it was."

My face turned bright red in the presence of truth. I had been caught being myself. Jan was being helped not by my fake professional calm, but my humanness.

After that, I came to a decision to consciously bring some of the wisdom and skill of my profession into my life with my children and husband at home. And I started bringing into the office the honesty and imperfection I had once tried to sequester in my personal life. Nowadays, I'm much more likely to tell a client that a teacher once told me how much she hated one of my boys, for instance, or that another son still does something with his shoulders that I think makes him look retarded and I sometimes yell at him to get out of the room.

I still think back on the moment Jan saw me in the grocery store, and I continue to be freed by it. In my office, I no longer work so hard to project tightly wound calm. Clients who haven't seen me in a while sometimes comment on how much more relaxed I seem. And I do feel less tense, having stumbled onto an old truth: it is me, not the image of professionalism I once thought I was conveying, that people find helpful and healing .

Linda Stone Fish is a professor, chair of the Department of Marriage and Family Therapy at Syracuse University and in private practice in Syracuse, New York. Address: Syracuse University, 008 Slocum Hall, Syracuse, NY 13244. E-mails to the author may be sent to Flstone@syr.edu. Letters to the Editor about this article may be sent to Letters@psychnetworker.org.

Friday, 02 January 2009 11:02

Tell the Truth

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To Tell the Truth

Letting Go of Our Inscrutable Facade

by Jay Efran

There is a basic inequality built into the therapy contract--we ask clients to disclose their vulnerabilities, while we hide behind a facade of unflappability, presumably floating above ordinary human foibles, untouched by the jolts and discouragements of life. We're not supposed to discuss our personal problems, or even acknowledge having any. While preaching congruence, who among us has never pretended fondness for a client we actually disliked, didn't understand and didn't trust? But on at least two ticklish occasions, with a minimum of strategic deliberation, I opted to step out from behind my own well-cultivated facade of inscrutability to tell clients the unvarnished truth--with surprising results.

The first time came at the end of a particularly long and trying day that had started promisingly enough in the office of a colleague with whom I had spent almost two years working on a book. But that morning, he informed me that after rereading the first three chapters--the part I had considered finished--he had come to the conclusion that the material had to be completely reworked. What was worse, changes in these early sections would affect everything else in our draft. He was talking about another year's work--if it could be done at all. To make matters worse, I could see at once that he was absolutely correct. I was so stunned that once he had finished delivering his verdict, I got up without a word and stalked out of his office. All I could think of doing was tossing the manuscript in the nearest trash can and calling it quits.

Walking home, I found myself spiraling into the kind of depression I hadn't experienced since I broke up with my most alluring high school girlfriend. I avoided my wife, went up to my home office, skipped lunch and didn't talk to anyone for hours.

In the middle of the afternoon, I glanced at the calendar and was dismayed to see that a client was due at any moment. I considered asking my wife to meet her at the door and explain that I had suddenly become violently ill--maybe some sort of food poisoning--and that I would be in touch to reschedule.

 

Then, for some reason, I felt a sudden impulse to go in a different direction--to simply tell the client the truth about what had happened that day. When Jenny, a perennially frazzled lab technician, came in and sat down, I immediately announced, "Today, I might be the one more in need of help." After describing what had transpired, I admitted that I had considered canceling but thought better of it. However, although I wanted to proceed with the session, I indicated that I was not planning to charge for it. After all, given my mood, I wasn't sure how much of my attention I would be able to muster for the task at hand. "In fact," I said only slightly tongue-in-cheek, "if you expect to use any 'air time,' you had better come up with some damn good problems to talk about."

In retrospect, I should have charged double. We soon became engaged in an energized give-and-take about how setbacks can convulse our lives and how difficult it can be to regain composure, even after the immediate crisis has passed. We both laughed about the ridiculously melodramatic pronouncements we usually uttered in the midst of such emotional distresses and the complexities of saving face later on. As we talked, I felt my own mood lift, but I also saw something emerge in Jenny that I hadn't seen before. She was proud of being able to gracefully yield center stage and empathize with someone else's troubles for a change. She liked the trust implied by my willingness to share my experience with her, and she profited from knowing that none of us is impervious to life's setbacks.

That evening, feeling much better, I called my coauthor, apologized for having "lost it" at our meeting and outlined a plan for digging into the repair work needed on our ailing manuscript. Restored by my time with Jenny and the freedom to acknowledge what had happened to me earlier that day, never again would I underestimate the value of just giving an upset client a safe place to vent.

Telling It Like It Is

A few years later, I had a chance to stretch myself even more with a client. Tim was one of the few clients to whom I have taken an almost immediate dislike. Referred by his wife, he carped nonstop about his thankless duties as a foreman in a small carpentry shop and his hassles with his in-laws, who lived just around the corner. His second session was more of the same, and I felt a growing irritation with his self-absorbed whining.

Midway through our third session, I found myself wondering how much longer this could go on. As Tim droned on with his litany of complaints, I became increasingly annoyed and confused. I knew we had gotten off to a shaky start, but I wasn't sure why. I sensed that it was time for decisive action, although I didn't know what. Then, I found myself uttering the following two statements: "Tim, I have two things to tell you," I said. "First, I don't like you. Second, I don't believe anything you have been saying." My words sounded harsher than I had intended, and in the silence that followed, I toyed with the idea of softening the impact with more nuanced words. But before I could recant, he said, "Frankly, I don't like you either. And besides, I think therapy is a complete crock."

"Now, those are the first things you said that I believe," I responded, and I asked him why, in that case, he had come in at all. He explained that his wife thought he needed help for his "temper" problem, and he had promised to give it a try. I told him that his wife's positive experience with therapy was not a sufficient reason for us to continue working together. He seemed relieved to be done with this charade and, frankly, so was I.

As he walked out the door, I was sure that was the end of it. Therefore, I was astonished when he called four months later to ask if he could stop by. He was the last person I had expected to hear from.

Talking to him this time around was like meeting someone new. He was warm and friendly, with none of the wary self-absorption that had once made me so impatient. He freely admitted that he needed help and confessed that--if I would still see him--I was his first choice for the job. We quickly formed a strong therapeutic partnership and worked together efficiently for the remainder of that summer. I grew to like and respect him, and I looked forward to each of our sessions.

Although he made a good living, Tim was a school dropout, while his wife was a college graduate. He told me he felt that his wife's family had never really accepted him, and he was always uncomfortable in their presence. He also felt out of place with his wife's friends, whom he considered stuck-up.

Tim could be quick tempered and judgmental, but I learned that he was also good hearted with a kind of boyish, down-to-earth charm. Through our work together, he lightened up about the reactions of others and less often felt a need to prove himself.

 

Later, he told me that the only reason he had returned after those initial meetings and was willing to let down his guard was that I had spoken so candidly. "I realized that I could always count on you to tell me the truth," he said. "I hate bullshit," he added, "especially my own!"

These days, I rarely hesitate to share my frank reactions with clients, most of whom, I have come to realize, are far hardier than we were taught to believe. If the setting is right, even brutal honesty can advance the therapeutic cause. In fact, over the years, I have discovered a very handy therapeutic mantra to consider whenever the work bogs down, "When you find yourself stuck, try the truth."

Jay Efran, Ph.D., is professor of psychology and director of the Psychological Services Center at Temple University. He is a coauthor of Language, Structure, and Change: Frameworks of Meaning in Psychotherapy. Address: Department of Psychology, Temple University, 1701 North 13th Street, Weiss Hall 413, Philadelphia, PA 19122-6085. E-mails to the author may be sent to J.Efran@worldnet.att.net. Letters to the Editor about this article may be sent to Letters@psychnetworker.org.

Friday, 02 January 2009 11:01

Can We Talk?

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Can We Talk?

Let's End the Conspiracy of Silence About Ethical Dilemas

by Mary Jo Barrett

It is the end of innocence--the day we enter the land beyond the rulebook. A client wants to give us diamonds. Another invites us to dinner. Another notices that we've stopped wearing a wedding ring, and we wonder how much to tell her. A client moves forward as if to hug us, and then gives us a open-mouthed kiss. Simple dicta no longer seem sufficient.

One way or another, all therapists face similar questions about therapeutic boundaries: Should we accept the gift? How much do we self-disclose? What do we do when a dual relationship can't be avoided? How do we safely negotiate the currents of sexuality? Moved by our best instincts, our weaknesses or simply by the sheer ambiguity of the situation, we can often find ourselvs striking out on our own and coloring outside the lines.

Once upon a time, when psychoanalysis was king, our ethical guidelines were as strict and sacred as the rituals for entering and leaving the Catholic confessional. We spoke the language of transference and countertransference. Both client and therapist knew what to expect: therapy was sacred work, done in a sacred time and space. Within the artificially private walls of the consulting room, human beings felt safe to tell a (usually male) therapist what they dared tell nobody else--relatively confident that they would not later encounter him at daycare or the grocery store. Back then, the dos and don'ts were unambiguous: take no gifts; don't self-disclose; avoid dual relationships; treat all clients equally; create clear boundaries between office and home; steer clear of sexuality.

Today, "therapy" no longer takes place in a book-lined study separate from secular space and time. The walls are porous. Competing models of the therapeutic relationship abound. Are we scientists, shamanic healers, secular ministers, paid friends, skills coaches or purveyors of psychoeducation? Each model contains its own assumptions and morality, and the old consensus on therapeutic ethics and boundaries has broken down. We can agree only on the most egregious forms of boundary violation: when a therapist makes millions as his client's record producer, or sleeps with him or talks about her at a cocktail party, we all know enough to shake our heads.

 

But once we leave the outrageous violations behind, new realities collide with abstract standards. Where do the "boundaries" lie when therapy can involve in-home visits or the building of a community support group? How do we avoid dual relationships if we practice in a town of less than 2,000 in the Yukon? When is self-disclosure helpful for clients, and when is it an imposition on them or a danger to ourselves?

All of us in clinical practice face these questions, or our own versions of them, almost daily. Yet, as the following stories of our colleagues' encounters with a handful of "sticky situations" show, it's remarkable how few of us talk to anybody about them. Where is our community of peers--that presumed source of sanity inhabiting the space between the ethics board and our solitary face in the bathroom mirror?

By not consulting one another, we have created a culture of avoidance. We use the word "boundary" without any common agreement on what the word means. As a result, we often wing it on our own, fearful of being labeled a boundary violator. We may decide that the situation is special, the client is special or we are special.

We hope that the following pieces--by therapists at every juncture in their careers--will open up a much needed conversation. Below, are accounts of therapists who found themselves unsure of how to deal with four highly charged areas of ethical ambiguity: self-disclosure, sexuality, gifts and dual relationships. Some of them took chances beyond the rulebook and were happily surprised. Others were not so fortunate. Few consulted with anyone at the time, but all are now sharing their stories with you.

The purpose of these articles is not to come up with a new rulebook. But perhaps these stories can begin to create a therapeutic culture where we openly discuss the moments that we feel our privacy or dignity violated--or that we risk violating those of our clients. Perhaps we can bring our embarrassment and uncertainty into our consultation and supervision groups. There, we might begin to create a consensus wider than our private morality, vulnerability and good intentions.

--Mary Jo Barrett and Katy Butler