Working with the
Client Who Has Experienced Abuse in a Previous Professional Relationship
by Gary Richard Schoener
Gary Schoener is a licensed psychologist and Executive Director of the Walk-In
Counseling Center in Minneapolis, MN. He is the senior author of "Psychotherapists'
Sexual Involvement with Clients: Intervention and Prevention", co-author of
"Assisting Impaired Psychologists", and has written many
articles on this topic. Schoener has consulted in more than 3000 cases of sexual
misconduct by professionals and was a member of the Task Force on Sexual Impropriety of the
American Psychological Association and its Advisory Committee on the Impaired
Psychologist. The Walk-In Counseling Center was the recipient of the 1977 Gold
Achievement Award in Hospital and Community Psychiatry from the American Psychiatric
Association.
This article has been reproduced with permission from the
Walk-In Counseling Center. Copyright © 1998 WICC.
Preface
Presented to the Norwegian Psychological Association in Oslo,
Norway - 3 & 4 September 1997. Edited by AdvocateWeb, with permission from
the author.
Introduction
Let us begin by examining personal variables and issues in the
therapeutic situation which can lead to difficulties in taking on this role.
Personal Issues/Variables: Some questions worth asking are:
Do you have any personal history with sexual abuse or serious
violations of trust? Will these present countertransference issues? A personal history of
abuse does not rule one out of doing such work, but it needs to be examined.
This can be challenging work and may take some time. Is this a good
time for you given the status of your personal and professional lives?
Do you have a good support base professionally? Do you have
consultants you can go to?
Do you have a reasonable tolerance for being challenged and
questioned?
Do you have a reasonable ability to deal with angry clients? Very
needy clients?
The Ultimate Countertransference Trap: Many times therapy involves
the therapist feeling like he or she needs to undo the bad deeds or failures of a parent
or significant figure in the client's life. Treating someone who has been victimized by
one of our own can be an even greater trap. The therapist can try to be "the perfect
therapist" who will bring about a corrective experience and undo the harm.
A Variety of Common Dynamics, which can lead to inappropriate
intimacy, can also affect such treatment work. Some followup helpers end up sexually
involved with the client:
Unconscious re-enactment of incestuous longings;
Wishes for nurturance can emerge & be quite powerful;
Rescue fantasies -- the countertransference trap of doing a better
job than someone's parents or previous therapist/counsellor;
Fantasy that love, or sex, are curative in and of themselves;
Repression or disavowal of rage at client's persistent thwarting of
your therapeutic efforts;
It is a fertile ground for acting out anger at organization,
supervisor, etc.
Defense against grief and mourning at termination;
It is an unreal world -- the "exception" fantasy;
A "safe" ground to experiment -- e.g. sorting out identity
confusions:
Cultural myth that the "right woman" can fix the most
disordered man
Informed Consent
With clients who have experienced unprofessional conduct, behaving
professionally is very key. Operating in a fashion in which there is a clear
contract which can be reviewed periodically is key to beginning. Informed consent requires
that the client knows what he/she needs to know to make a decision as to whether to enter
into counseling and as to what information he/she might be safe in sharing with the
counselor. At the very least, clients should be informed of the following items:
The cost of the counseling or treatment, including rules about
payment for missed appointments or incomplete treatment, cost of any testing, any issues
related to payment;
The limits of confidentiality: who has access to the records, any
mandatory reporting obligations (e.g. child abuse), or professional obligations to report
The general nature of the counseling, including techniques &
procedures used.
Reasonable expectations and potential negative outcomes of counseling
(e.g. that they may become more anxious for a time or remember unpleasant events).
Avenues for making complaints, including your willingness to deal
with their dissatisfactions
What About Recovered Memories?
The vast majority of cases of professional abuse do not involve
memories which were repressed and are later "recovered," although it is not
uncommon to put such memories out of mind for a time or to report them much later.
However, in a limited number of cases memories spontaneously come back and were truly
completely out of consciousness for some time. The American Psychiatric Assn. and American
Psychological Assn. have both prepared educational handouts on recovered memories of
abuse. Such cases are now a leading cause of complaints and lawsuits in the USA -- some
filed by third parties who are accused, and some by clients claiming later the memories
were planted.
If memories of abuse surface you need to be aware of the fact that
careful documentation of the manner in which they surfaced may be important. You need to
advise the client that it is difficult to know which aspects of any such memory are
accurate. This becomes more of an issue if the client intends taking some action based on
these memories.
It is prudent for clients to consider all possible outcomes of such
actions;
Clients need to know that your use of hypnosis or anything aimed at
further clarifying such memories other than simple discussion may cause others to question
the validity of the memories
If you are using hypnosis or other devices for "memory
recovery" you should note that there is no good evidence that this brings about the
recovery of completely accurate memories. This doesn't mean you can't do it, but just that
the client and you need to remember that the "memories" which are retrieved may
or may not to accurate.
Record Keeping
Some clients are quite distrustful and do not want any records kept, or
want to control what is in the records. This cannot be allowed. Your records are your
protection. You need to document anything necessary for:
providing a rationale for your diagnosis and treatment;
to satisfy any administrative requirements, contractual obligations,
requirements of government or required for payment;
to explain how you handled high risk situations. [so if there is
trouble, or a risky situation, your records should be more detailed]
Advocacy vs. Psychotherapy
Although psychotherapists are typically biased towards their clients'
viewpoints and as such can be said to be advocates for them, it is difficult to be an
objective therapist and also actively involved in advocacy. However, if you do not appear
to support the client's actions, he or she may not support you. It is important to examine
the options a client has and to help them sort them through. We use the Wheel
of Options for this -- it is attached as a handout. You can make up your own.
VIDEO: PSYCHOLOGY OF THE HEART
Reporting Issues & Challenges
As was noted earlier, you need to be clear BEFORE YOU RECEIVE THE
INFORMATION as to what your reporting responsibilities might be. This is particularly
important with regard to colleagues with whom you work.
VIDEOS: APA TAPE ON CLIENT OBSTACLES TO REPORTING
VIDEOS: APA TAPE ON PRACTITIONER OBSTACLES TO REPORTING
Both you and the client need to remember that it is the client's
complaint that is the important one. Your belief in the client's story is not of great
relevence nor is your complaint. Contrary to what most clients believe, the real complaint
is theirs. Without a complainant willing to come forward, action cannot be taken.
Conceptual Framework for Followup Treatment
It is critical to remember that client victims vary dramatically in
level of functioning and psychological history. We find nothing to differentiate them
premorbidly from the great range of clients who come in for treatment. This means,
however, that you may be dealing with someone who premorbidly was schizophrenic,
borderline, neurotic, personality disordered, or who was simply struggling with
situational issues and had no history of psychopathology.
As a result of the boundary violations the client may have experienced
severe breakdown, PTSD, severe depression, or made serious suicide attempts. By the same
token, he or she may not have felt harmed at all and may simply be contacting you to make
a report so that someone else is not harmed.
Trust & Safety
It is common for clients to indicate that they do not trust you. I
would advise supporting this by noting that it is not necessary for them to completely
trust you to get help. Furthermore, to indicate that you are not concerned whether or not
they trust you -- after all you are a stranger, and they've already been betrayed once --
but whether you can work out a contract to be helpful.
Trust and safety are established through professionalism: (1)
contracting; (2) being willing to listen to complaints or challenges and respond
straightforwardly; (3) maintaining boundaries; (4) not pushing for trust or intimacy; (5)
allowing client to withhold data until he/she wants to share it.
General Rules
In our book Psychotherapists' Sexual Involvement With Clients:
Intervention & Prevention (Schoener et. al., 1989, pp. 99 - 103) we presented the
following basic rules, which we still advocate:
Explore how the client feels about seeing you and offer
options if needed.
Focus intervention on crisis issues first -- maintaining health and
safety
Be clear as to why the client is seeking help from you -- what does
he or she want?
Clarify the current status of the relationship with the former
therapist, and identify any continuing communication or contact;
Avoid making assumptions about what type of sexual contact occurred.
The word "sex" does not always connote physical contact.
Avoid making assumptions about the gender or sexual identity of
either party.
Don't make assumptions about the impact of the sexual contact.
Identify what issues still need resolution and make a therapeutic
contract.
Don't just focus on the exploitation. Evaluate prior problems or
current crises.
Provide advocacy or refer the client to an advocate.
Some clients benefit from writing complaints and from writing
diaries.
Consider use of reading material to assist clients in understanding
the situation.
Consider a processing session with the client and the offending
professionals
Support groups are usually quite helpful if there is one available.
Over the years clients from whom we have had followup feedback have
listed two things as having been particularly helpful in recovery:
Talk with other victims/survivors, whether in a group or
individually;
Taking some sort of action, whether it be confrontation with the
professional, a complaint to an employer, a lawsuit, etc.
Ellen Luepker, who has done groups for victims for 17 years, has
recently completed a followup study on members of her groups and found that followup
therapy was also highly rated as a help.
Dr. Marie Valiquette (in her dissertation, and also in Lapierre, H.
& Valiquette, M. 1989 J'ai Fait L'amour Avec Mon Therapeute, Montreal, Quebec:
Editions St. Martin) found that the great variability in impact of the abuse washed out
differences and thus individual therapy did not show clear impact. She also found:
Recovery was better if blame was attributed to the former therapist,
but
An overly punitive attitude towards the former therapist was related
to ineffective coping;
Good social support combined with attribution of causality to the
former therapist led to decreased psychological consequences
The Spouse and Family
The spouse and family may suffer as much, or more, than the so-called
primary victim. We used to call these secondary victims. Luepker now refers
to them as associate victims in her excellent chapter in the Gonsiorek book Breach
of Trust.
VIDEO: THE PITTS
VIDEO: THE JANSSENS
When there is spousal support, treatment is much easier.
Criminalization has helped spouses conceptualize that this is victimization -- not an
affair. When there are children, if they have been neglected the victim often has great
guilt and shame about this fact. The disconnections with the family must be explored. The
family sees distancing, mood swings, irriability without apparent cause. The family may
have to severe certain ties, especially if the victimizer is a clergyman.
The spouse often feels a double betrayal. He or she has often had their
reality - testing challenged in a "gas lighting" situation. They are likely to
feel:
anger towards the victim, and the abuser both
distrust of professionals
impatience with the process of remedy and with the persistence of
symptoms
increased responsibility for the family
confusion & ambiguity
loss & grief
helplessness & frustration
We've done groups for spouses which are described in our book, but as a
practical matter it is unlikely that you'll have enough at one time to do them. One added
element when you as a parent played a role in your child being abused:
VIDEO: MAGNUSON
Family meeting and/or therapy:
Meet the Ghost: understanding what is happening; what has been
going on
Meet the Helpers: getting a chance to see the professionals
(who you don't trust)
Clarifying everyone's needs, and everyone's roles
Strategies for Mastery: information about process; complaints;
etc.
Helping in dealing with consequences: e.g. quitting church,
telling grandparents, etc.
Group Therapy
The key is to network with other therapists and send out notices to see
if you can organize even a small group. Consumer groups may also be helpful. Sometimes
groups for sexual abuse victims are helpful, but at times they are not understanding about
this type of abuse and do not feel that it bears any resemblance to incest or street rape
which they have experienced. We use a 10-12 session model which helps end the isolation,
provides support and encouragement, provides help in emotional expression, and provides
ideas for coping with challenges. The model is delineated in a series of chapters by Ellen
Luepker, Jeanette Milgrom, and Anne List in Psychotherapists' Sexual Involvement
With Clients: Intervention & Prevention (Schoener et. al., pp. 155-202). While
this work is challenging, we have demonstrated that with proper preparation and some
backup consultation, even an inexperienced group leader with no significant experience
treating this type of victim can co-lead a group effectively. The group members have such
a high need to end their isolation and to meet others who have had this, or similar
experiences, that they are very motivated, and typically respectful of each others. As
such, it sometimes seems that "the groups run themselves."
One Day Workshops
Rev. Marie Fortune and others have done these with victims of clergy,
and our center has done a few in connection with workshops. Estelle Disch in Boston has
done them for many years with considerable success. She authored a chapter in our book on
the topic which is worth consulting before running a workshop. Basically the day has each
participant briefly reviewing what happened to her, and her current status, and then
eventually each group member tries to discuss challenges and their future plans for
further action.
This can be done as a meeting, perhaps in an evening or weekend, where
there is a speaker, or the showing of a videotape, followed by discussion. People can
participate without revealing anything about themselves. This can lead to additional
meetings with more personal discussion, or person discussion may occur spontaneously. Each
of the major international conferences on this topic (Minneapolis 1986 & 1992, Toronto
1994, Sydney 1996) has had a meeting time set aside for victims, and in Toronto there was
a meeting for professionals who are also victims. A number of professionals who attend
such conferences are attending largely because they have been victimized by their pastor
or therapist or physician. (Note, Carolyn Bates, the senior author of Sex in the
Therapy Hour is a clinical psychologist.)
Reading Materials
Peter Rutter's book Sex in the Forbidden Zone, which is
in several languages, is still the most common book read by victims. Professional
articles, magazine and newspaper stories, and professional books are also useful to some
victims depending on what they want to read. Some of these clients have a great need to do
as much reading as possible. The other books we utilize are not likely to be readily
available in Norway: Ellen Plasil's Therapist was our favorite, but it is not even
available in the USA unless one finds it in a used book store. Derek Jehu's book Patients
as Victims , which came out in 1994 and is published by Wiley Books in London,
England, is fairly recent and has a nice overview of many aspects of the situation. A
number of chapters in our book Psychotherapists' Sexual Involvement With Clients:
Intervention & Prevention, are copied and shared with victims. So, newspaper
stories, magazines, and even professional journal articles may be of interest. Many
victims want to know "Why did he do this?" and are quite interested in
information on types of offenders.
Individual Therapy
It is very difficult to generalize about individual therapy for victims
of prior boundary violations since they vary so tremendously. Some are in very bad shape
and require hospitalization or medications for severe PTSD symptoms, psychosis, severe
depression, suicide or homocide threats, etc. At the other extreme are those who mainly
want help and support on a very short term basis as they file a complaint.
The most common therapy goal is the sorting out of the experience,
and the second most common goal is treatment of the problems which were not effectively
treated previously. The greatest challenge is to help the client retain any real
progress achieved in the prior therapy while sorting out and rejecting aspects of the
therapy which were part of the abuse or exploitation.
With some clients there are significant transference problems linked to
the prior abuse -- with others there are not. Some clients press the therapist's
boundaries, wanting hugs and other personal contact, having liked these in the prior
therapy. They find simple talk less satisfying than the intensity of the relationship
which became abusive. Some try to challenge boundaries as a way of testing your
reliability. Others are quite angry and thus will argue over fees, missed appointments,
etc. and ask for special favors because they are "victims." THE BASIC RULE IS TO
DO NOTHING DIFFERENT THAN YOU NORMALLY DO. YOU ARE GENERALLY SAFE WHEN YOU PRACTICE WITHIN
YOUR OWN STYLE AND APPROACH AND AT RISK WHEN YOU DEVIATE SIGNIFICANTLY. The issue of
record-keeping, for example, was discussed earlier.
Over the years we have heard from many clients about their follow-up
therapy. The most common errors we hear about are:
(1) Failure to Forewarn the Client of the Limits of Confidentiality,
or Violations of Confidentiality: Many therapists have not carefully thought through
their reporting duties, such as those required in cases where the abuse occurred when the
client was a minor (child abuse reporting) or reporting required by rules or ethics codes.
The most common situations in which the therapist fails to forewarn the client, or where
the therapist violates confidentiality are:
(a) Cases in which, when the offender is identified, the therapist
realizes that he or she is a supervisee, supervisor, consultant, co-worker, or student of
the therapist. The therapist then feels duty bound to confront the person, or to report
the situation.
(b) That the nature of the complaint and likelihood that others are at
risk triggers an ethical dilemma in the therapist who feels a moral obligation to take
action. This is something you need to know about yourself before the client reveals the
identity.
(c) Through carelessness, when the therapist seeks consultation, or
tells a colleague without carefully disguising the case. Norway, like Minnesota, does not
have a huge population and the professional community is relatively small. It does not
take too many details to tip somebody off as to the identity of the victim or the
offender. If the offender has not been identified, you may also find out later that he or
she was the person you went to for consultation, not knowing that the complaint was about
them.
Note that the client can be instructed that he or she does not have
to tell the identity of the person for you to be able to help them. That is optional.
However, in some situations you already know the identity because the client blurts it out
before you warn her, or because you know who the prior therapist was because you were the
source of the referral.
(2) Setting Limits Relative to Your Willingness to be Involved in
the Legal or Complaint Process: Many practitioners try to avoid situations in which
they have to testify or become involved in legal processes. There is nothing wrong with
that. However, as a practical reality in ALL CLINICAL WORK, a practitioner may be called
upon to make a report or statement relative to a legal matter. To say that you "don't
want to be involved" in a sexual misconduct complaint will be interpreted by the
client as non-support or protection of ones colleagues.
I cannot imagine what problem there is with supporting a client who is
making a complaint through proper channels, regardless as to how convinced you are of the
complaint's accuracy. Nobody benefits from rumour or complaints that are passed on the
"grapevine" rather than through complaint channels. Once a formal complaint is
made the professional can defend him or herself. You cannot defend against rumors. You
need simply to support the client, help process his or her reaction to the complaint
process, and certify to what they have told you. Your opinions or beliefs about the
complaint are secondary -- the adjudicatory body has to judge the validity of the
complaint.
(3) Pressuring the Client to File a Complaint: Just as the old
practice of discouraging the filing of a complaint is not helpful, one can go to the other
extreme and push the filing of a complaint. We saw a videotape earlier illustrating this.
This choice is the client's, and he or she will suffer the consequences. No complaint
process is without anxiety and pain. Clients are often ambivalent about taking action, but
ultimately it needs to be their choice. Your main role should be to help the client
address their ambivalence by gathering information about the complain options and
determining which are the best to use given the client's goals and situation.
(4) Undue Focus on the Client's Anger or Other Negative Emotions:
Not all clients are angry, and to press a client for years to "get in touch with your
anger" is disrespectful and abusive. Stay away from formulas as to what clients who
have had this experience are feeling. As we indicate in our book, and as other authors
have indicated (e.g. Bisbing, S., Jorgenson, L., & Sutherland, P. [1996] Sexual
Abuse by Professionals: A Legal Guide Charlottesville, Virginia: Michie), Pope's
"client-therapist sex syndrome" has no empirical support. While some clients
have virtually nothing but anger and negative feelings, others have predominately positive
ones. MOST CLIENTS HAVE VERY MIXED FEELINGS.
Some aspects of the prior therapy has often been quite positive and
some of the feelings, for example, of gratitude are reality-based. In fact, when positive
feelings are quite strong the client will have great difficulty because therapists, other
victims, family, etc. will not want to hear these. They are the hardest feelings to
process or understand. Many followup therapists have trouble accepting these and discount
them as the result of transference, denial, neurosis, identification with the aggressor,
co-dependency, or delusion. To help the client you need to assist in exporing and valuing
all feelings -- positive and negative. Actually, the positive feelings are very important
in that they help the person:
(a) Understand why he or she is so confused about the
relationship;
(b) Understand why he or she had difficulty leaving the relationship;
(c) Provide clues as to what the client was seeking interpersonally;
(d) Improve self esteem and shore up reality testing by giving credit
for positive changes made before the therapy went bad
(5) Bending Rules for the Client: As was noted previously,
bending rules for clients who have been victimized is rarely a good idea. The
countertransference trap of trying to undo the harm done by an imperfect or exploitive
therapist can set the stage for a repeat. You don't need to prove anything. Radically
changing your own personal rules by allowing for frequent phone calls, home phone calls,
longer sessions, etc. sets the stage for an erosion of professionalism which is never
good.
(6) Undue Focus on the Client Trusting You: As was noted
earlier, the client will not trust you and should not trust you, based on prior experience
and the fact that you are a stranger to them. If trust develops due to your
trustworthiness, fine, but don't work at it. We reinforce clients for acknowledging their
distrust. Focus on the therapy contract and working on goals. They can decide later if you
were trustworthy.
The Processing Session
There are times when clients ask the subsequent treating therapist to
meet with them and the former therapist. You need to think about this very carefully.
There are a number of issues:
What are the limits on confidentiality -- you will now be hearing of
the situation from both parties. Is this session confidential? Are there any reporting
duties?
What obligations, if any, will this produce in you to ensure that
other clients are not at risk? What if your opinion is that this may not be isolated, or
the therapist admits to other offenses, or you clinically observe symptoms of serious
emotional problems?
You need to distinguish this from couples counseling. You cannot do
individual therapy on the victim and couples counseling for the relationship.
If you agree to such a meeting you need to make it clear that it is to
gather more information and to help the client process what is going on. It is not
designed to help the former therapist OR to help their relationship continue. Note that clients
often try to re-establish contact with the former therapist and that this can be an excuse
to do this.
The Processing Session, which is discussed in our book, focuses
on a quasi-therapeutic processing of what happened between the two. It is similar to Mediation,
but mediation involves attempting to settle a dispute or reach an agreement. Processing
involves attempting to achieve understanding and to get explanations. Our processing
sessions typically involve:
Meeting in a neutral site, with clarification as to
confidentiality and purpose;
The victim's recounting of her memory of the events, from the
beginning of the relationship, through the therapy process, and then examining boundary
breakdowns;
A chance for the offender to respond and present how his memory is
similiar or different;
Attempts by the processor to establish common elements in the
memories;
- A summary at the end as to points of agreement and disagreement.
Walk-In Counseling Center (WICC) grants permission for a printout to be made,
but asks that multiple reproductions for use as handouts be made known to them.
Please contact them, if you are considering this, to see if they have a more recent
handout or one even more suited to your intended purpose. Any use should properly
credit the sources -- WICC and the AdvocateWeb site
(http://www.advocateweb.org). For permission to reproduce more than one copy,
contact: Walk-In Counseling Center, 2421 Chicago Ave. S., Minneapolis, MN 55404.
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