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Setting Clear and Ethical Boundaries with Clients

Section 15
Setting Clear, Ethical Boundaries in Group Therapy
By G. R. Schoener

Question 15 | Ethics CEU Answer Booklet | Table of Contents
Social Worker CEUs, MFT CEUs, Psychologist CEs, Counselor CEUs

Patients who have been sexually involved with their therapists, in most cases, seek some kind of help after the damage occurs. They apparently do not change disciplines but frequently change their choice of genders of the therapists they consult.

It cannot be emphasized enough that the subsequent therapist must be aware of the therapeutic issues and the special needs of this population. The volatility, hypersensitivity, emotional liability, and fragility of these patients make demands on the emotional resources, the time, and the therapeutic skills of the subsequent therapists. When the modality chosen is group psychotherapy, there are additional problems.

The Post-Therapy Support Group (PTSG) at the University of California, Los Angeles (UCLA), was founded in 1982. It was decided in the planning state that this would not be an advocacy program. Housed in the Psychology Clinic, the program began with a colloquium to a group of advanced graduate psychology students who responded with interest to an invitation to participate in the program.

Euphemistically named the Post-Therapy Support Group, emphasis was placed on the supportive nature of the project. Licensed psychologist Janet L. Sonne, who is a member of the UCLA clinical faculty, and five advanced graduate students—Debra Borys, Roberta Falke, Valerie Marshall, Buf Meyer, and Tony Zamudio—began the training and committed themselves to a program that offered no credit or compensation. Subsequently, psychologists Laurie Astor-Dubin, Allison Parelman and graduate students Sherry Adrian, Delia Magana, David Miranda, and Judy White joined the project. Months of training and planning ensued.

Three-hour weekly meetings were held featuring a number of guests who addressed various aspects of therapist-patient sex and the systems that were involved in dealing with the consequences. A senior special investigator for the Board of Medical Quality Assurance explained the complaint process and the preliminary interviews with the complainant and the respondent.

A deputy attorney general detailed the administrative law process, the various licensing boards, their structure and function. An anonymous patient who had been sexually involved with a therapist spoke to the group about the emotional impact and the sequelae of her sexual involvement with her therapist.

Self-help versus therapy groups. A former chair of the American Psychological Association Ethics Committee addressed ethical issues and the processing of ethical complaints filed by patients who had had sex with their therapists. The founder of a self-help group addressed the question of self-help versus therapy groups. Several psychology diplomates offered information about group work and therapy with survivors of victimization processes.

When approximately six months of initial training were completed, we turned our attention to recruitment. Patients were obtained by distributing brochures describing the purpose of the group to community agencies and local therapists. An article in the Los Angeles Times resulted in many inquiries, and several televised interviews about the program resulted.

As they responded, potential group members were interviewed by the PTSG graduate students. MMPI’s were administered in individual sessions. The results were discussed by the project staff and feedback sessions were held with the patients.

We used our assessment sessions to try to determine which patients were in a position to benefit from outpatient group treatment, and which patients might respond better to other approaches (and for whom group therapy might be contraindicated).

We made every effort to ensure that those for whom group therapy was not the treatment of choice had access to more appropriate resources. Among those alternative resources was individual therapy either within the clinic (with sliding-scale fees) or with a therapist who was experienced in this area of practice and who maintained an office geographically convenient to the patient.

A major concern was that those patients who were not included in the group would feel rejected. Indeed, patients frequently expressed the feeling that they were being tested to see if they were “worthy” of admission to the group. This sensitive area is one of which all therapists should be aware.

As the project progressed, however, we found that the criteria for admission to the group did not need to be so strict. Some patients who suffered extreme distress and dysfunction, for whom outpatient group therapy would seem to be contraindicated, managed to work quite well within the group context and to benefit substantially from this modality.

All of the group participants were female until the third group began. A male patient applied to join, and there were some concerns on the part of project members about how he would be received, and how he, as a lone man, might feel in group. Some of the patients in the group expressed discomfort with the idea of including a man as a member of the group, but through discussion and exploration, they determined that he was “also a victim” and decided to include him.

Whether it was because of this particular individual or the preparation or the character of the group itself, the experience was a very positive one for all involved. We have not as yet included any male project members as group leaders, although we are seriously considering the possibility. We are now beginning the fourth year of the program and the fourth group. Some of the original staff members are still with us, returning from community agencies or internships to donate time.

The PTSG project staff found that consultation with current therapists of patients who were sexually involved with a previous therapist provided an important service to the community. In two instances the current therapists had had no experience with this type of patient and requested consultation by group members. We welcomed the opportunity to provide written material about current research on therapist-patient sexual involvement and to discuss the special needs of this population.

Inexperienced therapist. In one instance a young, inexperienced therapist from the community asked if the patient should be transferred to one of the supervisors, and we were able to reassure her that the positive relationship that she now had with the patient was crucial in the recovery. It was important to assist the present therapist in understanding the difficulties of establishing the transference relationship and in recognizing the countertransference that arises in so many of these cases.

The patient’s mistrust of his or her own feelings and suspicion about the motivation of the new therapist is a double bind that can be frustrating to the treating therapist. Since patients feel that they cannot trust their own judgment (and they cannot since they have tangible evidence that their first choice of therapist ended in disaster for them), they must turn to someone else on whom they can rely.

Their families, generally, have not understood the problem and have either denied its existence or have blamed the patient. Since they do not trust men (usually the therapists were male) and do not trust therapists generally, unremitting testing ensues with anger, reproach, threats, demands, and depression. However, growth is often dramatic and may alternate with partial regression. As you know, it is frequently helpful to have a consutlant, "on call" for suicidal threats. Dependence is another double-edged sword.

These patients are very needy and reach out constantly, but they are angry with their dependency and blame the therapist for encouraging that dependency. Yet, if it is withheld, they cannot function and are in danger of suicide. The agonizing nature of these conflicts is a challenge to the resources of both patient and subsequent therapist.

A problem that repeatedly surfaced in the PTSG was the continuing ambivalence toward former therapists. Much as an abused child may have positive feelings for the abusing parent and will defend that parent against attack, these patients were sensitive to any derogatory remarks made about their former therapists. Almost all experienced problems with boundaries, understandable in light of their previous involvement with therapists who violated therapy boundaries.

Group members had difficulties setting appropriate boundaries in their relationships with each other and with their new therapists. For example, one member feared she might slip into a caretaker role in the group at the expense of getting her own needs met. Many called each other, needing to talk and gain support, but fearful lest they might overtax the relationship. Others felt guilty when they limited the phone time they made available to group members on request of spouses and/or children.

Several revealed that they continued to have difficulties establishing boundaries, and were currently involved with a new therapist, a professor, or a supervisor. Testing of the boundaries set by the group leaders was also frequent. Invitations to dinner, requests for longer sessions, and endless phone calls had to be evaluated in terms of not only the neediness and suicidality but also the desirability of holding to desirable boundaries. Consultation was also very helpful in this area, where many decisions were complex.

Most important was the extreme vulnerability and fragility of these patients, which they themselves experienced. They recognized their need for help but rejected that help. Sophisticated in the language of therapy because of their long exposure to the process, they recognized the typical therapeutic responses and challenged the group leaders.

Reflecting responses, comments on process, or any kind of confrontation would evoke flashes of anger. Yet group members recognized the complexities and the contradictions involved and could on occasion even sympathize with the group leaders, but basically they rejected the “therapy” model. They were most comfortable when they themselves were talking and when the therapists only made supportive comments. Frequently they spent hours after the sessions talking in the halls outside the therapy room or in the parking structure.

In and outside of the group they would discuss the problems of how much to trust, recognizing that the previously complete trust had been ill-advised. Recognizing that they have to trust someone, they struggled with the question of how far should they trust and how could they assess trustworthiness. Several times there was a growing awareness that they (group members) were responsible for their own growth, that they should open themselves and talk about their feelings in order to get better. But they also needed to feel that they had a choice in doing so.

The group process appeared to follow these patterns:

1. The beginning sessions dealt mostly with a recounting of the traumatic incident. Group members were eager to share their experiences, and there was a great deal of support in evidence when the narrator broke into tears in the telling of the story. Emotionally, most of the group members blamed themselves for what occurred and expressed guilt over their role in the sexual relationship. Self-abasement and denigration of their behavior were quite common.

2. As awareness of common patterns began to develop, there was diminution of self-blame and a growing recognition that the sexual involvement was the therapist’s responsibility.

3. Anger and rage began to surface, although positive feelings toward the therapists were also present and caused many emotional outbursts. Some filed charges at this point. Not all of the group members moved to this stage at the same time, and those who felt positive feelings for their therapists were challenged by those who were angry. It was continually necessary to emphasize individual differences and the right to make choices about whether or not to take action.

4. Fear, anxiety, and depression began to surface. Those who had filed against their therapists began to have fantasies about being chased, harassed, and even murdered by the previous therapist (such fantasies are particularly understandable in light of the violent threats made by many sexually exploitive therapists).

Some fantasized about killing their therapists and were frightened by their own anger. Some would stalk the therapist, watching the windows of the office, or speculating on whether the therapist was sexually involved with the patients observed entering the office. Anxiety arose about the depth of the anger felt and about the possibility that there could be acting out and that they could not control their impulses. There was much self-doubt at this point; the feeling that they would never recover from the trauma.

5. The growth of insight became apparent. There was rejection of the previous therapist; the recognition that the sexual involvement was based on the therapist’s own personal problems. However, the loss of trust became more acute, and there was emergence of skepticism, humiliation, embarrassment, loss of dignity, continued self-blame for having been so easily duped, and so on, but with an intellectual awareness that these feelings were transitory.

6. There was a tentative emergence of trust. A beginning willingness to trust themselves and their own judgment. A recognition of their own power and of their growing independence. A sense of freedom to choose whether to be further involved in working for legislation in the area of patient­ therapist sexual involvement, or to say no and move on with life without feeling guilty.

Group members were able to ask for help and appreciated when it was given, but it had to be given on their terms. Sensitive to the leaders and to each other, the groups were eventually able to build trust, express positive as well as negative feelings, and to go on with their lives. Consensus of the project members is that this kind of specialized clinical work is very difficult but very satisfying, as is evidenced by the longevity of the project.

In addition to the work with the PTSG group, project members frequently were called on to present in-service training to community agencies and continuing education workshops at the conventions of the various disciplines. Empirical research was contemplated initially, but the special sensitivities of group members to possible exploitation and fear of being used for the therapist's own needs precluded that possibility for the present.
The article above contains foundational information. Articles below contain optional updates.

Personal Reflection Exercise #7
The preceding section contained information on group therapy. Write three case study examples regarding how you might use the content of this section of the Manual in your practice.

QUESTION 15
What was a key issue PTSG group members had to face? To select and enter your answer go to
Ethics CEU Answer Booklet.

 
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The article above contains foundational information. Articles below contain optional updates.
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