The Pragmatics of Hope

What to Do When All Seems Lost

by Yvonne Dolan

It was a completely full morning flight to Los Angeles. Despite the post 9-11 security procedures, our United Airlines flight was actually leaving on time. Everyone, passengers and crew alike, seemed in pretty good spirits. Then I noticed the man seated across the aisle. He was hunched over, his face in his hands, the muscles in his back shaking. He nodded almost imperceptibly when the attendant gently touched his shoulder and reminded him to fasten his seat belt in preparation for takeoff.

A few minutes into the flight, I heard the muffled sound of sobbing. After a few minutes, I leaned across the aisle and asked, "Are you okay?" He shook his head. "Is there anything I can do?" Again, he shook his head.

A little later, a flight attendant walked down the  aisle, noticed the man's sobbing, and asked, "Do you need anything?" He shook his head and cleared his throat.

"My wife and all four of my kids were killed last night in a car accident. I'm on my way back to Hawaii to make the funeral arrangements. I moved over here [the flight had originated in Chicago] for my work." His voice broke. "They were going to join me when the school term ended. "

"I don't know what to say, sir," the attendant said gently. "I'm so sorry. Are you sure there isn't anything I can get you?" Again, he shook his head. "I just need to get through the next two flights, so I can do what needs to be done. Our family is all flying over from the mainland for the funeral and I'm going to have to pick them up and make arrangements. I was up all night last night after they called me, so I'm going to try to get some sleep."

"Ring the call bell if you need anything, sir, "the attendant murmured. As she walked away, the man looked across the aisle at me. "I just need to focus on what needs to be done. That's the only way I can get through this." Then he folded the airline blanket across his chest and closed his eyes.

To most people, this man would hardly qualify as "hopeful." His misery and his story make it easy to conclude that he was, literally, without hope. Easy, but wrong. True, he undoubtedly felt hopeless, but he was not hopeless, he had not succumbed to despair. Even in the face of his catastrophe, he was taking small, tentative but active, steps back toward the realm of life. By focusing on what he needed to do in the immediate future--get some sleep, pick up his relatives, and begin making arrangements--he was assuming a future, a time for which plans needed to be made, people contacted, tasks met, even if, for now, that future encompassed only the next few hours or days. Despite his acute grief, he was saying, in effect, "this is impossible, but I'll find a way to get through it."

Making his plans didn't change what had happened or his feelings about it, but it gave him some small measure of control in otherwise uncontrollable circumstances. It also provided him with a rough map for what would undoubtedly be a brutal journey through a wilderness of suffering. For the time being, he was alive and coping; he hadn't been defeated by despair, and that in itself was a harbinger of hope to come.

There's Hope in Activity

As therapists, we've been trained to think that we should focus primarily on emotions. We often elicit negative emotions, believing that they must be purged before there'll be room for hope and other positive emotions. We're particularly anxious to assuage trauma survivors, whose desperate, unbearable pain seems to demand immediate relief. We frequently assume that all clients must feel hopeful and believe that life is meaningful before they'll make much progress in therapy or in life.

But the fact is that in the wake of catastrophe, it's often impossible to summon up the least glimmer of hope or faith or sense of life's meaning. How, for example, can you suggest to someone whose child has been shot in a schoolyard, who has lost a home to a hurricane, or who's been raped as a child by family members that there's hope for the future, that they'll feel "better" someday? To clients who have suffered such profound trauma, it's ludicrous to suggest that they can be coaxed into feeling hopeful about the future.

In these cases, the trauma therapist may be in something of a bind. Trying to "drain off" negative emotions by focusing on the pain--asking clients to rehash what happened or to speak repeatedly about their terrible feelings--is likely to make them feel worse. Just asking such clients an open-ended question about their emotional state--"How do you feel today?"--may exacerbate already terrible feelings or call forth a sense of numbness and apathy.

But favoring positive emotions and subtly trying to subdue negative ones can backfire. Asking these clients to imagine a time when they won't feel suicidal or reframing their trauma as an opportunity to "grow" can trivialize their suffering and inadvertently insult them. These efforts may also strike them as manipulative, as though the therapist is trying to maneuver them into a hopeful response they're not ready for.

How do we get beyond this impasse? We can begin by looking again at the ways people have found consolation and support in the thousands of years   before psychotherapy was developed. Throughout history, human beings have found rough relief and a modicum of comfort in the immediate obligations and habits of ordinary, daily life. The greatest incentive to go on coping lies in their relationships with other people, not only those who comfort and support them, but those who depend upon them. Sometimes, the simplest act can have profound power. I learned recently of a Red Cross survey given to disaster survivors, asking them to name the most helpful "intervention" they'd experienced right after the disaster. Many said they most appreciated being given a cup of coffee by an aid worker. It wasn't fancy trauma therapy, but I suspect the familiarity and ordinary helpfulness of the act implied to survivors that, in spite of catastrophe, normal life was still going on. In receiving a cup of coffee lay some small kernel of hope for the future.

In my 25 years of treating traumatized people, I've found that in these crisis situations dissecting negative emotions or trying to rev up positive ones isn't the most useful step we can take. This isn't to say we should avoid discussions about how clients feel--far from it. But talking with clients about what they're doing and how they're coping provides not only a framework for them to talk about how they feel, but a real-life scaffolding for the eventual construction of more positive emotions. Hope follows action, rather than the other way around. Helping clients become aware that what they're doing--even if it's "merely" coping and "just" getting by--can be the first step toward rebuilding their sense of agency and control.

I first began thinking about the healing power of activity and its "hope-implicit" quality when I was a young therapist-in-training, working in a shelter for abused and runaway teenagers. Every one of these kids had experienced severe and prolonged abuse, and virtually all suffered from acute post-traumatic stress. As an all-night staff person, my job was to help them get to sleep--an almost impossible task because for my charges sleep was a realm of nightmares and flashbacks. Talking with them about their traumas just heightened their distress, and asking them "positive" questions--about what they wanted to do with their lives, what they liked, what would make them feel safer--didn't engage them.

Desperately casting around for a solution, I began to ask more specific questions about the immediate future. "What would you like to do tomorrow? What do you need to get that done? How will you know tomorrow night that you had a decent day?" Several said they wanted to contact brothers, mothers, or friends to find out if they were okay. Others said they wanted to go outdoors; they'd been cooped up inside for too long. Still others said they wanted to wash their hair, take a bath, get clean clothes. This doesn't sound like therapy, nor does it provide much in the way of emotional breakthroughs. But it worked. Talking about practical, immediate plans calmed them down and helped them sleep. I believe that the practical details of their lives reminded them that they were more than their traumas, and gave them concrete realities that, at least momentarily, jostled them out of their inner turmoil.

Drawing on my shelter experience, I work with trauma clients to help them identify actions they can take to keep going. But sometimes trauma clients no longer have a sense of who they are and why they should continue living--except that they feel they have to go on for the sake of their kids, their grandchildren, their spouses, or even the person they've lost. Many clients who cannot imagine going forward for themselves can summon up some last ounce of strength on behalf of those they love.

Focusing on Day-to-Day

Germaine, came to see me after her adolescent son had been killed in a gang-related shooting. She'd just lost her job, was drinking heavily, and was almost paralyzed with grief. She entered therapy not to make herself feel better, but so that she could go on living for the sake of her other two children.

At that point, nothing I could say would make her feel better. I told her how sorry I was for what happened to her son, and how painful I imagined this must be for her whole family. "How have you managed up until now?" I asked. This focused her on what she was doing and offered her an indirect opportunity to express her feelings. Germaine said she'd been going to a support group, and while it helped to get dressed, get out of the house, and be with others, the overall experience wasn't particularly useful. "I feel like I'm being swallowed up by how much it hurts, like I could, literally, drown in the pain."

Germaine was a former crack addict, but had been clean for six years. She'd resisted taking drugs again, but she was drinking heavily. "These feelings aren't ever going to go away," she said. "And just talking about it isn't going to cut it. I have to have some sort of concrete plan of what I'm going to do to fill up the time or I'll die of grief. What am I going to do?"

Of course, I didn't know the answer. But clients often have within themselves the budding solutions to their own dilemmas, though they may not recognize it at the time. Germaine had come up with a potential way out of her hell when she said she needed a "concrete plan" of action. I thought we should try to construct one. I asked her if there had been anything at all that had helped to make these past few months a little bit more bearable. She was silent for several minutes, staring at the floor.

"It helps when I make a list," she said finally. "Some days, when I get up in the morning, I make a list of what I need to do and, somehow, those days seem to go a little bit easier--maybe because I have a plan, sort of like a map for getting through the next few hours. When I don't have my list, it's a lot worse. I can just sit and cry all day."

I asked her how the list helped. She said that it wasn't so much the list itself that helped, but that the act of making it put her completely in the present. Listing the most mundane chores--"go to grocery store," "pick up Michael's shoes from repair shop," "make kids' lunches for tomorrow"--and then doing them helped her "get back to living, at least for the time being," she said. In a sense, she could do hope before she could feel hope. This focus reflects a great human wisdom found in many major spiritual traditions: that being consciously mindful, maintaining full awareness of what's going on in the present can bring some solace and peace when all else fails.

It struck me that concentrating on her list-making and following through with the tasks when she felt so terrible must have taken extraordinary effort. "How did you do it?" I asked.

"I guess I just made up my mind."

"But just how did you make yourself get up in the morning?"

"I told myself I had to do it."

"What did you do to convince yourself?"

"Well, I gave myself a lot of shit, as I lay there, telling myself it was a lousy thing to do to my kids--just let them fend for themselves while I wallowed in bed."

This pursuit of minutiae can have a powerful impact on the client. In answering the questions, Germaine acknowledged her own agency and strength. If I were to praise her, no matter how sincerely, for managing to get up every morning, it might have sounded condescending. Focusing her attention on what she was doing for herself helped her to recognize her own strength and her ability to keep going despite her pain.

I saw Germaine weekly for a year and a half, keeping the focus on her own efforts. One of the most powerful and respectful ways to help clients actively find new meaning for their lives is to ask them to imagine someone who loves them telling them what they're accomplishing. When I asked Germaine what she was doing right, she responded like many depressed and grieving people that she wasn't doing anything right. So, I rephrased the question, "Well, imagine that your kids are remembering what you did during this past week. What would they say you'd done right?" After a pause, she said, "I guess they would say that I'd put a meal on the table every night, and that I took them to church on Sunday, and that we went to the movies one evening." Once, I asked her what a favorite aunt, who was deceased, might have said to her. For the first time, she smiled softly and said in a small voice, "She would tell me I was doing good, taking care of the kids and all, and that she was proud of me for not hitting the bottle at the end of the day."

Session by session, Germaine gradually began to immerse herself in the mundane stuff of daily life, and her despair seemed to lessen over time. But  she seemed to grow more anxious about her children. She worried that she hadn't been a good enough mother, expressing guilt for neglecting them while addicted to crack. She wondered if she'd been responsible for her son's death. Now, though still grieving for the one she'd lost, she felt increasingly frightened for the other three, and anxious about her own capacity to guide them through childhood.

"Suppose that you dream that many years have passed and your children--who are now adults--are sitting around the kitchen table with you, telling you that you did a great job as a mother and describing all the things you did completely right while raising them," I said. "Now, suppose you wake up and can't remember the dream, but find yourself doing all the things they said made you a great mother. What would be the first things your kids would notice you doing?"

Germaine closed her eyes and smiled. "I would go to every parent-teacher meeting. And I would make sure they told me where they were going to be every hour of the day--even if they fought me on it. And I would help them with their homework. And I would push them to finish school. I would keep on loving them, and let them know how much I loved them every day." Because she was already beginning to do some of these things, it slowly dawned on her that she was already becoming the kind of mother her kids needed.

By asking this type of question, the therapist makes a kind of hypnotic suggestion that communicates--indirectly, without ever denying the client's ongoing pain--that there is something significant to hope for. If the question is worded right, the client will answer it not by expressing a wish for the impossible, but by setting out realizable goals. I didn't ask Germaine the kind of question that would provoke her to wish for her son to be alive again. Instead, she could wish for something entirely achievable, through her own efforts--something that would help her become the mother she wanted to be.

Starting with Baby Steps

Though focusing on mundane tasks in the present can seem impossibly beside the point for someone who has suffered a life-shattering event, it can help build, inch by inch and then yard by yard, a pathway out of despair and into the fullness of life. A Japanese doctor told me a story about how powerful this kind of mindfulness can be. Mr. Tanaka, a recently retired patient of his, had been admitted to a hospital after trying to commit suicide. For nearly 50 years, Mr. Tanaka had suffered from severe back pain as a result of tubercular meningitis he'd contacted at 15. He'd endured 30 operations, to no avail. Every treatment--physical therapies, nerve-blocks, drugs--had failed. Indeed, the pain was getting worse and he was now confined to a wheelchair. Stuck at home and in constant pain, he'd lost all hope and had attempted suicide. The doctor asked him how he'd managed to get through his painful life to that point.

"Well, I'm a very optimistic man at heart, and that has helped me," Mr. Tanaka answered. "While the pain was awful, I just buried myself in work, which relieved it a tiny bit. I also believed the pain would become much less some day--and that made me optimistic. But now that I know I'll never have relief, I feel there is no hope."

Not knowing what else to offer, the doctor grabbed at this lifeline. "Could you do something for me?" he asked Mr. Tanaka. "When you feel even a little bit more comfortable, please notice and remember the occasion, and notice why and how it occurs."

Each time he saw Mr. Tanaka over the next few weeks, the doctor encouraged him to notice when his pain was less severe. For six weeks, nothing. But one day, Mr. Tanaka came in smiling. "Since you began asking me to notice times I feel better, I've been thinking about it. A couple of days ago, on the way home from the dentist, I stopped in the park by the riverside. I ate sandwiches and fed the crumbs to the pigeons. They started going after the crumbs, and I really enjoyed watching them. In fact, I became so absorbed in watching them that I didn't have any pain at all while I was there!"

The doctor encouraged him to continue noticing other times he became so involved he didn't notice the pain. Gradually, Mr. Tanaka noted more and more activities during which the pain disappeared. He also noticed that the pain didn't seem to be getting any worse. He began gardening and fishing and even took a short trip with his wife. Seven years later, the doctor told me, Mr. Tanaka was still improving.

Strangely enough, the "distraction" of living fully in the present seems to be the only real cure for the terrible things life can do to us, the only real source of hope in hopeless situations. As therapists and healers, we can't make people feel hopeful, nor can we reverse the tragedies that make them feel hopeless. But we can help them slowly begin building, out of life's own materials, a place in which hope can nest.

Yvonne Dolan, M.A., specializes in trauma treatment. She is the author or coauthor of 5 books, including Resolving Sexual Abuse. Address: 7137 Knickerbocker Pkwy., Hammond, IN 46323. E-mails to the author may be sent to yvonne@yvonnedolan.com. Letters to the Editor about this article may be sent to Letters@psychnetworker.org.

The Untold Story

Carol Gilligan on Recapturing the Lost Voice of Pleasure

by Mary Sykes Wylie

In the early 1980s, soon after the publication of psychologist Carol Gilligan's In a Different Voice , Lauren Slater, later to become the author of such daringly autobiographical works as Prozac Diary and Lying , was an unfocused psychology graduate student at Harvard, struggling (and failing) to write fiction. She decided to take Gilligan's lecture course in developmental psychology, a decision that changed her life. "Even in this large lecture hall, she created this sense of connection and intimate discovery," recalls Slater. "Listening to her, I could suddenly see that my difficulty wasn't that I had writer's block or no talent or a lack of motivation, but that I was disconnected from myself and my own particular voice. Fiction, for me, was all about artifice, wearing masks, putting words into made-up characters' mouths, and making up 'pretend' voices. I had spent much of my life talking in a 'pretend' voice, and I needed to say things straight, in a voice that was my very own."

This dawning revelation of a long-suppressed private self simmering below the surface is exactly what legions of women felt while reading In a Different Voice by Gilligan, which today remains among the most influential feminist works ever written, as Zeitgiest-altering in its way as Betty Friedan's The Feminine Mystique . Gilligan's In a Different Voice has sold more than 750,000 copies (an astonishing feat for an academic book), and has been translated into 17 languages. After 20 years, it's still a staple of virtually every gender-studies reading list in America.

Now, Gilligan, after coauthoring and coediting five books with her students, has written The Birth of Pleasure, which is, she says, the "culmination of a trajectory" begun with In a Different Voice. Where Gilligan previously called for a different voice, now she's writing in a different voice. She draws on her research with adolescent girls and also her work with young boys and adult couples in therapy to highlight a path of resistance to the losses of voice and relationship that she documented in her previous work. With the Psyche and Cupid myth, which she uses to frame her discussion, and a range of plays and novels, poems and diaries, she places evidence drawn from contemporary research in a broad cultural and historical context to explore the psychology of love and the relationship of tragic love stories to patriarchal cultures. Again, she's working in the tradition of clinical analysis and narrative research, rather than statistical analysis of numerical data. In joining research evidence and literary examples, The Birth of Pleasure is cut from the same cloth as In a Different Voice, even if the weave is more intricate, the structure more complex, the design more sweeping.

So, why is it that critics seem either to love or hate this book? There's been virtually no neutral response. University of Cambridge psychologist Terri Apter in the Times Literary Supplement describes the book as a "thrilling new paradigm." Robert Coles chose to run a long excerpt from the book in Doubletake under the title "A Radical Geography of Love." In the Boston Globe, columnist Ellen Goodman calls it a "bold and boundary-breaking book." Eve Ensler, author of The Vagina Monologues , says that "Gilligan's book does no less than reconfigure what it might mean to love and be loved, a revolutionary act in itself."

And yet, other reviewers seem to be taking part in a public stoning, attacking her book with the ferocious glee of the Taliban cornering a heretic. " The Birth of Pleasure fails on nearly every level . . . a sticky paste of unproven assertion, anecdote-as-data and swaths of memoir," writes journalist Emily Nussbaum in The New York Times. Reviewer Judith Warner of The Washington Post found the book "horribly dated. . . . It rambles . . . it meanders. . . . It is solipsistic . . . . I couldn't make heads or tails of it." "Smudgy thinking . . . poetic obscurantism . . . psychology gives way to mystagogy," writes Margaret Talbot in The New Republic.

Controversy is one thing, and by no means a bad thing, for a writer with a history of challenging received opinion. But, the reaction to The Birth of Pleasure seems extreme, often veering from criticism to outright contempt. Catharine Stimpson, dean of graduate students at New York University, wonders in a recent article for the New York Observer (titled "Who's Afraid of Carol Gilligan?") why reviewers of The Birth of Pleasure, itself a "hopeful vision of happiness and love," appear to be taking part in a "cultural blood sport," whipping up "some of the most disparaging reviews I've ever seen." What's this orgy of journalistic abuse all about? Is the book really so terrible? Or is there something about the message in The Birth of Pleasure that makes it even more disturbing than In a Different Voice or Meeting at the Crossroads --both of which were also attacked, although not with the same venom. Or are we living in a different era in which the kind of feminism that Gilligan represents now seems out of synch with what today's tough-minded, presumably long-since-liberated women want to read?

IN A DIFFERENT VOICE challenged theories of psychological development--based on studies of men and boys only--that, since the time of Aristotle, had assumed women were inferior to men in their capacity for moral reasoning and lacked a clear sense of self. Gilligan showed how women's voices, once heard in their own right and with their own integrity, change the conversation by drawing attention to aspects of human experience that previously were dismissed or silenced. The different voice was a relational voice. In contrast to an ethic of justice linked to ideals of autonomy, independence, and self-sufficiency, Gilligan described an ethic of care linked to realities of relationship and enjoining responsiveness, responsibility, and carefulness rather than carelessness toward oneself and others. It was an ethic based on a more psychological understanding of the human world.

After the social explosiveness of '70s feminism, Gilligan's book didn't initially seem all that radical. Low-key and nonpolemical, In a Different Voice didn't catalog outrages against women or attack men or male supremacy. Yet it effectively challenged the supremacy of an intellectual tradition built on the idea that, literally, psychology is the study of man . The book struck an emotionally-resonant chord in a whole generation of women, who recognized themselves in its pages--their own vague and undefined sense of not being heard, of learning to put on their own "pretend" voices. "Gilligan's book changed my view of feminism," says Carol Hekman, professor of political science at the University of Texas at Arlington, who had already written her own book about feminism. "She challenged the idea that there is one, singular and absolute path to either philosophical or moral truth. In fact, her view of feminism challenges the entire Western tradition--you can't get more revolutionary than that."

The claim doesn't seem entirely exaggerated. Gilligan's work inspired a flood tide of research and scholarship in fields ranging from psychology to ethics, literature to law. Gilligan's research with girls following the publication of In a Different Voice similarly led to a wide range of educational, artistic, and cultural projects designed to encourage girls' voices and build on their psychological strengths. Primary and secondary schools throughout the country responded to Gilligan's call to help girls resist conventions of femininity that were psychologically and intellectually costly (conventions that required girls to be nice, to silence an honest voice, and suppress vital parts of themselves) by developing more girl-friendly curricula and teaching methods. She's often credited with being the spirit behind the 1994 Gender Equity in Education Act, which banned sex-role stereotyping and gender discrimination in the classroom. Her work also gave a big boost to the study of differences in the way men and women communicate, resulting in both serious scholarship and pop-psychology sensations like Deborah Tannen's You Just Don't Understand and John Gray's Men Are from Mars, Women Are from Venus.

Not surprisingly, as one of the few academics who also has become a popular superstar, Gilligan has come in for numerous honors. The first Graham Professor of Gender Studies at Harvard and a recipient of the prestigious Heinz award for her contributions to understanding the human condition, she also was named "Woman of the Year by Ms. Magazine in 1984, and one of "America's most influential people" by Time Magazine in 1996. In fact, Hollywood superstar Jane Fonda was so taken by Gilligan's work that she donated $12.5 million to Harvard in Gilligan's honor to create the Harvard Center for Gender and Education. The coauthor and editor of a series of books on gender and development over the past two decades, Gilligan initiated the Harvard Project on Women's Psychology and Girls' Development, a program called Strengthening Healthy Resistance and Courage in Girls, and retreats for women educators and therapists called "Women Teaching Girls/Girls Teaching Women." She also became artistic codirector of an all-woman theater company, The Company of Women, and founded the Harvard Project on Women's Psychology, Boys' Development and the Culture of Manhood. Recently, after nearly 35 years at Harvard, Gilligan moved to New York to become University Professor at New York University, where she's affiliated with the law school, the graduate school of arts and sciences, and the school of education.

In The Birth of Pleasure, her first solo-authored book since In a Different Voice, Gilligan shows how the tragic love story reflects a process of cultural initiation and is tied to an ancient agenda (think Abraham and Isaac, Agamemnon and Iphigenia) that even now is played out in the fears of connection that shadow the lives of men and women. Why, Gilligan asks--and sets out to answer--do we keep reliving this old story, generation after generation; why do we reinstate the contradiction between democracy and patriarchy that dates back to 5th-century Athens? Why are so many couples afraid to truly open themselves to each other? Why are there such walls of silence between men and women? Why do boys, at 4 or 5, begin to hide their vulnerability and cover up their feelings in order to become "real" boys? Why do girls, at 12 or 13, begin to conceal what they're really thinking, stop "seeing what they see, knowing what they know," and begin second-guessing themselves?

The short answer is that emotional truths and the ability to "say what we see, know what we know" go underground in the interests of the long-standing patriarchal order we call civilization. Gilligan defines feminism as the movement to end the age-old contradiction between democracy and patriarchy. Patriarchy, in her view, isn't a battle between the sexes but a system that constrains both men and women; literally, it means a rule of fathers, separating some men from other men, fathers from sons, men from women, thus "introducing hierarchy in the midst of our most intimate relationships, between parents and children, between lovers." The stifling constraints of patriarchy are passed on, generation to generation, and compromise our psychological development from early childhood, hobbling love, making pleasure dangerous, and enforcing taboos against truth-telling.

The Birth of Pleasure is reminiscent of Freud's Civilization and Its Discontents --but with one striking difference. Where Freud sees tragedy as inescapable (symbolized for him by the Oedipus myth), Gilligan sees a history of psychologically driven resistance, as manifested in the myth of Psyche and Cupid---a myth that ends with the birth of a daughter named Pleasure. She observes that as patriarchy forces a break in intimate relationships, thus inhibiting love, so love holds the power to uproot patriarchy. People can, and do, resist society's iron framework; they can find a true voice within themselves and heed what they know through experience.

The Birth of Pleasure isn't an easy read. It's a complex, idiosyncratic, many-chambered labyrinth of a book. The style is often elliptical, with sections linked together more by association than logical sequence. In fact, it may be that the book's critical reception--both positive and negative--stems as much from its medium as its message. Catharine Stimpson suggests that Gilligan is bucking a literary trend; these days, people have grown suspicious of bold, intellectual leaps, preferring straightforward, linear argument, written in plain, muscular prose, and backed up with scads of numbers. The Birth of Pleasure is clearly not that kind of book.

Despite the initial hailstorm of attack, The Birth of Pleasure may well be considered, as the positive response suggests, as much a classic in the realm of psychology and social commentary as In a Different Voice. Though it's too soon to have hard sales data, the book appears to be selling well--perhaps as well, or better, than In a Different Voice, when it first came out, and Vintage Press will soon publish a paperback version. Networker readers will have an opportunity to gauge their own response to Gilligan's message when she delivers a keynote address based on The Birth of Pleasure at our annual Symposium next March in Washington, D.C.

In a recent conversation, Gilligan, no stranger to public controversy, seemed cheerfully philosophical about the polarized response to her new book. Looking elegant and youthful--with her long skirt slit up the side and silver bracelets--she seems to have more affinity with the world of art and theater than social science. She laughs often as she speaks and has a way of drawing out the people around her, inviting confidences that makes it only too easy for the interviewer to want to tell her about his own life story. In the following interview with Networker editor Richard Simon, she talks about some of the connections between her life and work that she hasn't discussed in print before and offers her view of the historical transformation she believes we're now undergoing. Throughout. she projects a calm certainty, seeing her work as part of "a quiet revolution in the human sciences" that holds the potential of changing our view of ourselves and our lives.

-- Mary Sykes Wylie

Psychotherapy Networker: Here I'm sitting with the Tiger Woods of interviewing. Can you give me some pointers. How do you approach the people you interview in your own research?

Carol Gilligan: I approach them with a desire to learn from them or to discover with them what they know. Research is very different from therapy, in that therapy starts when someone arrives with a problem, a desire for help, a wish to sort out something. Research begins with the researcher's question. So I begin by asking a question and then I listen--and the way of listening is key. How do you listen when you want to discover another person's inner world, as opposed to figuring out where someone falls on your map of the world? In the research leading to In a Different Voice, I wanted to discover how people speak to themselves about themselves and about morality at a time when they're facing an actual choice, meaning one in which they'll have to live with the consequences of their decision. I was going to interview Harvard students--men facing the Vietnam draft--but then the draft ended and the Supreme Court legalized abortion, so I interviewed a diverse group of pregnant women who were considering abortion.

In the kind of discovery research I do, the relationship is critical. A woman once said to me: "Do you want to know what I think, or do you want to know what I really think?" How do you approach someone when you want to know what they really think? I think I have a good ear for the rehearsed story, and then I listen for the story under that story. I find that when I tell someone, "Here's my question, this is why I'm here, this is what I'm interested in learning from this conversation," and then listen as best I can to what they're saying, I can ask almost anything in pursuing my question because the lines of the relationship are clear. The more I speak for myself, I think, the more they're likely to do the same.

Here's a good example. At the end of a five-year research project, I met with the girls who had participated to ask them how they wanted to be involved, publically, now that we were presenting our findings at conferences and preparing to publish a book. I was meeting with the girls in 9th grade, who had first been interviewed when they were 9. Their first response was, "We want you to tell them everything we said and we want our names in the book." But then Tracey, imagining encountering her 9-year-old self in a book, says, "When we were 9, we were stupid."

There are many things I could have said at that point; I could have paraphrased what she said, or repeated it back, or tried to reassure her by saying, "No, you weren't stupid." Instead, I said what I was thinking: "You know, it would never have occurred to me to use the word 'stupid' because what struck me most about you when you were 9 was how much you knew." At which point, Tracey said: "I mean, when we were 9, we were honest."

I've found that if I say what I'm really thinking and feeling, people are more likely to say what they really think and feel. The conversation becomes a real conversation.

PN: Isn't trusting your own reactions in that way tricky for a researcher? How do you make sure that your own biases and assumptions don't color the answers you get?

CG: That's a good question, and it goes to the heart of how I think about research. I think of research as a relationship. If you stick to your list of questions no matter what the response, if you cover your own thoughts and reactions, then how will this kind of nonresponsive relationship color the answers you get? I don't think there's a psychologically or culturally neutral situation. If you say nothing, you leave prevailing cultural biases and assumptions in force, and the people you're studying will have their own biases and assumptions about what you're after. You could try to fool them by deceiving them, but I think people are pretty savvy in reading the human world. So I try to negotiate my relationship with people and for myself; I strive for a kind of Zenlike innocence, where I work from a genuine position of not knowing.

In The Birth of Pleasure, I write about a couple in which the husband is obsessed with whether his wife has had an affair. He says that his "ultimate nightmare" is "her in the arms of another man." Now, I know the culture of male honor, and in this sense, I understand what he's saying, but I also can think of worse nightmares. So I say: "Why is this the ultimate nightmare?" And he says, "I guess the ultimate nightmare, really, for me, was to never have the opportunity to show her how I really feel and to be a family man, to open my heart, and to love her." I was taken completely by surprise. I never imagined this response, but it's the moment that interests me most, when a gap opens between the "I" and the culture. The moment when a voice that has been held in silence suddenly speaks. What's key here is that my question was a genuine question.

PN: What do you mean by a genuine question?

CG: Something I'm genuinely curious about, so in that sense it's a real question, something I don't know the answer to or even the range of possible responses--because I never would have anticipated the husband's response. Sometimes, one question builds on another. Once I discovered how astutely girls can read the human world, I wondered can't boys do this, too?

PN: Reading the hostile reviews of The Birth of Pleasure, you'd think that feminism isn't only dead but has become almost a dirty word. One critic dismissed the kind of feminism you represent as "horribly dated," and others have taken you to task for laying all our social ills at the feet of patriarchy.

CG: To me, it's ironic to pronounce feminism dead at the point in history when women's votes are determining the outcome of elections, when most American families no longer resemble the Dick-and-Jane patriarchal family, when more women are gaining an economic foothold, when feminism has opened a new conversation about domestic violence and sexual abuse, and when so many women worldwide have no effective voice and are living in poverty. I define feminism as the movement to end the contradiction between democracy and patriarchy, and I see us now as being in the midst of this struggle. Patriarchy means a hierarchy, a rule of priests in which the priest or hieros is father. It separates some men from other men, fathers from sons, and all men from women. Patriarchy isn't dead--look at who runs the Fortune 500 companies and Congress--but it's in trouble. Look at Enron and WorldCom, and the scandal in the Catholic Church and the FBI and CIA.

I say in my book that the most volatile moment in therapy is when people begin to envision the new. Then it's very tempting to turn back, because at least the old is familiar, "I love my neurosis, I know the whole script." So, given all the remarkable changes that began with the Civil Rights movement of the 1960s and have led to social and cultural shifts that are on the scale of the Protestant Reformation, it doesn't surprise me that we're now seeing something akin to the Counter-Reformation, and even the Inquisition.

PN: Let's go back 20 years to the publication of  In a Different Voice, which was for many people a landmark book that brought a feminist voice into the social sciences. How did it occur to you to write that book?

CG: At the time, I was in my thirties, had finished my Ph.D., and had no intention of going on in psychology. I was the mother of three small children, a member of a modern-dance troupe, an activist in the Civil Rights and the anti-war movements. My husband was a psychiatric resident and I taught part-time to make some money so I could have some help in the house. I had the opportunity to teach with Erik Erikson at Harvard in his course on the life cycle and then with Lawrence Kohlberg in his course on moral and political choice. In the course of teaching, I became interested in how people respond to actual situations of conflict and choice, and I started doing some research with a few graduate students, focusing on turning points in people's lives, times when the "I" surfaces around the question of "What do I want to do?" and morality comes into play around the question "What should I do?" I interviewed people and I listened for a first-person voice and also for moral language, words like should and ought and good and bad and right and wrong.

In 1975, we moved from Newton to Brookline, and I stayed home that year to help my three young sons settle into a new school and neighborhood. I was interviewing pregnant women who were considering abortion, and I remember sitting at my kitchen table reading over the interview transcripts and suddenly hearing a difference between the terms of the public abortion debate (right to life vs. right to choice) and the women's concerns about acting responsibly in relationships, because for many women, the abortion dilemma was a dilemma of relationship. Listening to these women, I heard a conception of self and of morality that differed from Erikson's and Kohlberg's theories.

I remember my friend Dora came in and I said to her, "I can see why these women don't fit into Erikson's or Kohlberg's stages--they're starting from connectedness rather than separateness. And Dora said, "That's really interesting. Why don't you write about it?" So I did. It was the first time I wrote something that wasn't for school. The essay, "In a Different Voice: Women's Conceptions of Self and of Morality" was published in the Harvard Educational Review in 1977. In a Different Voice came out in 1982.

PN: When did it first dawn on you that this book was going to have the sort of impact that it's had?

CG: On the day I went to pick up the retyped manuscript from a woman who lived in a working-class neighborhood in Somerville. Harvard press had sent it to her, and when I arrived, she said that she hoped I didn't mind, but she'd given it to her cousin upstairs to read and her cousin wanted to meet me. It was at that moment that it occurred to me that the audience for the book might be much wider than I had ever imagined.

What many people don't know is that when the book first came out, it got very mixed reviews. Kirkus Reviews said, in effect, "Nothing new here." The  Times reviewed it, which was great, but the review was mostly lukewarm, except for one very strong, positive sentence, which then was widely quoted. Arthur Rosenthal, the director of Harvard University Press, made a brilliant publishing decision to bring it out very quickly in paperback and price it low so it could be a second course adoption. An editor at the press told me that what I wanted was slow, steady sales, which is what happened.

And then people I didn't know began talking to me about the book. A woman working in a local store asked me, "Are you the woman who wrote that book?" and then said that I had explained her marriage; a Globe reporter stopped me on the street and said that I had explained his divorce. Many women have told me they remember where they were when they read the book, and how they felt suddenly that what they really thought or felt about things made sense. The book spoke to and also about a voice inside them that told them they were wrong or stupid or crazy; it challenged the legitimacy of that voice. So many women felt heard and able to speak in a new way. And the book also legitimized for men a voice that had been associated with what were seen as women's weaknesses, but which I identified with human strengths.

PN: So what was it like to become revered suddenly as this feminist icon?

CG: I don't see myself as an icon. I was very moved by the response to my book; it brought me into relationship with many people whom I otherwise would not have met. I also discovered that in becoming a public figure, I became a focus for all kinds of projections that had little to do with me. And then I became a focus of political attack, because In a Different Voice was seen as encouraging women to listen to their own voices--like the Soccer Moms in the 1996 election who didn't vote with their Republican husbands.

What many people don't know is that at each step along the way, my work has been both celebrated and contested. After In a Different Voice came out, a symposium was held at the next meeting of the Society for Research in Child Development. Three leading women psychologists were on a panel organized to criticize my work. There was no voice of support, and I was to respond to my critics. The symposium was held in the ballroom. I felt I was being invited to the Star Chamber. After Meeting at the Crossroads, the book I wrote with Lyn Mikel Brown about our research with girls, I was attacked in cover stories in The Nation, The New Republic, and The Atlantic, two of which were entitled "Gilligan's Island," as if in working with girls, I had separated myself from reality.

PN: What were the main criticisms and how did you answer them?

CG: They had to do with my use of the word "different" and also with questions of method. I had said very clearly in In a Different Voice, that the "different voice I describe is identified not by gender but by theme." My point was that including women changed the voice of the conversation, leading both women and men to hear themselves and one another differently. Including women shifted the paradigm--this was what I demonstrated in my book. Just as the girls' research revealed girls' resistance to an initiation into ways of seeing and speaking that made it hard for them to say what they saw or know what they knew through experience.

I think the response to my work was due to the fact that so much of what I said rang true. I remember Catherine McKinnon saying to me, "What I hate most about your work is that it's true," meaning women often do speak in the way I describe, which she saw as the result of women's oppression. Psychologists criticized my research because I didn't do statistical analysis, but my questions weren't statistical questions--how much, how often, how many. As a colleague who studies language pointed out, to illustrate a difference, all you really need is one example.

My question was, given that the major theories of psychological development had been written on the assumption that man=human, what difference does it make to include women? What can be learned by listening to women and girls? And my writing offered an answer to those questions. But it was a little crazy-making for me to hear people describing the differences I heard and then arguing that there were no differences. Eleanor Maccoby subsequently apologized to me for this, but I remember her introducing the panel at SCRD by saying "A colleague, male of course, stopped me on the way to the ballroom and said 'I'll see you at the shoot-out at the OK Corral,'" which got a big laugh, and then she proceeded to read her paper, which basically said there were no sex differences.

PN: So that was the intellectual side of the controversy. But emotionally, how did you handle all this hubbub?

CG: You have to remember, I had been active in Civil Rights, in the anti-war protests, and in the women's movement. I was a Swarthmore College graduate with a deep appreciation of the Quaker tradition of simplicity and a suspicion of conventional markers of success. I saw the controversy over my research in political terms, as a fight about a paradigm shift that had widespread implications. I also was embedded in relationships that sheltered me from the controversies of the academic world. I spent a lot of time with my children, my husband, and my parents, who were still alive at the time. It was a very different time. In June, when school got out, I'd take my kids and go to Martha's Vineyard for the summer. I never worked in the summers. My identity didn't center on my position at Harvard, which was very part-time for many years. I wasn't invested in becoming a member of the Profession of Psychology. But psychology, small p, fascinates me--understanding the human world and how it works.

PN: In a Different Voice was a direct challenge to two extremely distinguished academics with whom you had worked very closely, Erik Erikson and Lawrence Kohlberg. How did they respond to having their work called into question.

CG: You want to know how the "fathers" responded? I had taught with each of them after finishing my PH.D. I respected their work enormously and learned from them--about the importance of placing life-history in history, about the necessity of talking about questions of value. I didn't see myself as challenging them but challenging the paradigm or theoretical frame. This is where they didn't agree with me. Larry and I taught together after In a Different Voice, and taught explicitly around our disagreement as to whether the differences introduced by women's voices could be accommodated within his theoretical framework, or whether they implied a paradigm shift.

I used to tell women graduate students, half-seriously, that the role of slightly rebellious daughter was one of the better roles for women living in patriarchy. And as I loved my father, I felt very warmly toward both Erik and Larry. Larry wrote a blurb for my book. But if I had to paraphrase what they thought, I'd say: "I like her, she's bright, she writes well, she's fun to be with, and it's important for women to study women. But change my theory--you've got to be kidding."

And then, because my work implied a change in theory, there was a concerted effort to discount or refute that challenge, which Larry Kohlberg and his supporters were involved in. I remember hearing after the meeting of my tenure committee that Larry had represented the psychologists' response to my work as entirely negative, which wasn't true. He ignored the strongly positive review of In a Different Voice in Contemporary Psychology and the journal articles supporting my findings. To get tenure, you had to do work that changed the field and, clearly, I had done that. So I confronted Larry and, using his language, said it wasn't fair--that I had done as much as he had done when he was tenured. He asked me what I wanted him to do (by this point, the dean had taken him off the review committee) and I said I wanted him to write a letter saying this and supporting my tenure, which he did. I think he had become too identified with his theory.

PN: In The Birth of Pleasure, you describe discovering your memories of pleasure with your mother and also some of the difficulties in your relationship at the time of your own adolescence. She seemed to be the primary bearer of cultural messages about femininity.

CG: My discovery that Anne Frank, when she edited her diary, omitted her descriptions of pleasure with her mother led me to ask myself how I had edited my memories of my relationship with my mother. What surprised me was how accessible my memories of pleasure with her were, once I found the key. It was a Proustian experience.

For Proust, the lost time that he recovered was a time in early childhood. For me, it was early adolescence. These are times of heightened risk in boys' and girls' development, and through my research, I came to connect this risk with the initiation into patriarchal gender codes that occurs earlier for boys than for girls. Proust saw his mother as carrying the burden for this initiation, and I saw my mother as doing the same.

Once I recalled my memories of pleasure with my mother, I could understand better the confusion I experienced when she'd shift from being in relationship with me to teaching me what I needed to do in order to have "relationships" in the world at large. There was one incident around In a Different Voice, when she spent an entire day reading galley proofs with me, which was so meaningful to me, especially given the substance of that book. We sat on the red sofa in my living room together, and then after we finished, she picked up one of the pillows and said, "You have to remember to fluff up these down pillows," which I heard as a criticism of my housekeeping. So there it was, both sides of our relationship.

PN. So much of your work has been about voice and the psychological costs of feeling silenced. You've just described people taking issue with your voice. What was it like to have your own voice challenged in that way?

CG: The hardest times for me were not when people challenged what I said, but when I felt my voice was not heard. When people talk about me or my work in ways that have little or nothing to do with me or with what I've written, or when they speak about me as though I don't know the first thing about research, I wonder what's going on. For example, In a Different Voice isn't a book about how all men differ from all women--I give examples of men using the "different voice" and of women speaking about rights and justice, and say clearly that I'm contrasting two ways of imagining self and relationship that leads to different ways of speaking about moral problems. My title is In a Different Voice, not "In a Woman's Voice"--the question is different from what, and I contrasted women's voices with what was then the voice of psychological theories. The danger, for me, lies in starting to doubt my own writing. Virginia Woolf writes about this danger for women writers, when the infection enters the sentence and you begin within your sentences to double-think yourself in anticipation of not being heard.

PN: Critics have either loved or hated The Birth of Pleasure. How do you understand the intensity of the reaction?

CG: Well, I'm writing about pleasure and also about leaving patriarchy, which are two fraught subjects. I link tragic love stories with the initiation into patriarchy and then show how the findings of contemporary research provide us with a map showing points of resistance and ways leading out of destructive cycles. It isn't surprising to me that people might disagree with me or argue that the evidence I present doesn't support my interpretation. What surprised me was the vehemence and the personal nature of the attacks, which had little to do with the argument of the book, but more with my past work or with the structure of the book, which was incomprehensible to some readers. But I was writing about dissociation, how to break through a wall that separates you from what you know, and I followed an associative method, because you can't argue your way out of dissociation. The structure of the book is orchestral, or like a tapestry with different threads woven together to show a pattern. I wanted to recreate for the reader the journey I had taken in coming to see what I saw. My title, The Birth of Pleasure, reflects the importance of the research I did with girls in leading me to these insights (the Psyche myth that frames the book ends with the birth of a daughter named Pleasure) and also announces a paradigm shift--from a paradigm grounded in experiences of loss ( The Birth of Tragedy ) to one grounded in experiences of pleasure. One colleague speaking of her own experience in reading the book, said: "This book unsettles an adaptation," which is what I intended.

PN: Over the past 20 years, lots of thinkers and practitioners have been trying to bring a feminist perspective to bear on therapy. What are you saying in The Birth of Pleasure that hasn't been said before?

CG: What I can add to this very important conversation about therapy are findings from developmental research. What I think is especially relevant is the discovery that voices that can be clearly heard among young boys and preadolescent girls then become covered by other voices, so it's difficult to remember accurately without actually hearing the voice that's become dissociated from oneself or that's being held in silence. The remembered voice is very different from the actual voice of times before dissociation sets in. A second contribution has to do with realizing the extent to which psychologists have read culture as nature, so that adaptations to patriarchal structures are taken as inevitable facts of human existence. Here my research is instructive because it highlights a resistance that isn't ideologically driven but is like the immune system, a force for psychological health.

PN: You end The Birth of Pleasure by saying: "We have a map. We know the way." What does that way look like?

CG: It's a way of staying in relationship with the different parts of oneself, with others, and with the world. It means not giving up relationship, which is part of our birthright, for the sake of having "relationships."And the key here is pleasure. It's hard to fake pleasure, although perhaps for this reason, pleasure has gotten something of a bad name, becoming associated with license or irresponsibility rather than with joy and with freedom. Pursuit of happiness. It's part of the Declaration of Independence. The loss of a voice grounded in experience, including experiences of pleasure, compromises love, but it also compromises democracy.

PN: I know that The Birth of Pleasure isn't a clinical book, but is there any advice you'd offer therapists that might be helpful to their work with clients?

CG: I'd encourage them to listen for the untold story, which is often a story about pleasure. When I joined Terry Real as a cotherapist working with couples, I was struck by how often a story about pleasure lies underneath a story about loss. Anger at mothers--which is crucial to hear and respond to--is often closer to the surface; what often goes unnoticed are memories of pleasure. A man I call Dan was coruscating in his descriptions of his mother's intrusive behavior, and it would have been easy to overlook his saying, almost in passing, "My mother and I were buddies, we were pals."

I'd tell therapists to pay attention to resonance, because voice depends on resonance. We're surrounded by cultural resonances that affect what can and can't be said and heard. If a therapist wants to hear a voice that's been ignored or discredited, he or she will have to create a resonance that signals the possibility of this voice being heard. We know this now with respect to trauma. The Birth of Pleasure does this for love.

PN: What's particularly interesting for those of us who identify you with your research with girls and women is how much of your new book is about boys and men. I was especially struck by your statement, "Within a patriarchal society and culture, mother and son are a potentially revolutionary couple."

CG: I speak from experience, as the mother of three sons. What's revolutionary is this relationship. If sons stay in connection with mothers and mothers with sons, the patriarchal plot cannot go forward, because it depends on breaking this relationship. I know how often I felt pressured in the name of psychology or for the sake of my sons' masculinity to separate myself from them or them from me, as if our knowing each other would stand in the way of their becoming men. It would stand in the way of their seeing the world through a patriarchal lens, which loses the interiority or subjectivity of women. Olga Silverstein has written very powerfully about the courage it takes to raise good men. And many of us have now done this, and the implications are revolutionary, calling for new ways of structuring both work and family life.

PN: So here's my final question. How does The Birth of Pleasurer reflect your own experience of marriage?

CG: I knew you'd get around to that. I write about my own dreams in the book because if something is true psychologically, it's true for me, too. And the same is true with pleasure. Like many people of my generation, meaning those of us who married before all the rules changed, I've been in many marriages with the same person. When I think about marriage I think of the infant research, showing that relationships follow a tidal rhythm--finding and losing and finding again. So Jim and I will lose our experience of pleasure with each other, and then we'll find it again, and it's the finding that's crucial. What's important is not to get stuck in the loss, to resist the pull of tragic love stories. And then sometimes pleasure comes in unexpected ways. I remember Jim showing me the opening of his first book and my intense pleasure in reading it. He was describing his experience as a boy growing up in Nebraska, looking up at the night sky and seeing the Milky Way, and the writing was so exquisite and naked and emotionally true, it was the voice of the man I had fallen in love with, a voice I find irresistible. And there it was on the page in front of me.

I see The Birth of Pleasure as a hopeful book. I hope it's not foolishly optimistic. I wanted to encourage people to listen for the voice of pleasure in themselves and in others, to stay with the vulnerability of joy, and to cast a skeptical eye on tragic love stories.

--Richard Simon

Mary Sykes Wylie, Ph.D., is a senior editor of the Psychotherapy Networker .

Richard Simon, Ph.D., is the editor of the Psychotherapy Networker and author of One on One: Interviews With the Shapers of Family Therapy . Letters to the Editor about this article may be sent to Letters@psychnetworker.org.

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.

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.

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.

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.

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.

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.

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.

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