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 SaÂ´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.
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.