Facing Ethics, Privacy, Sexual Issues, Boundary Violations, and Retirement as an Analyst (article)

I would like you to accompany me on my personal journey. Along the way, I hope to demonstrate how my two analyses, feminism, and my career have changed me. Simultaneously, I will comment on the sea change in ethical conundrums that we therapists face. On this virtual trip, I will linger at three ethical issues that have demanded the most of my attention: confidentiality, boundary issues, and the aging analyst.

I became interested in ethics, not because I was a philoso-

Page 180

pher/scholar, but rather because in Chicago I was one of the only young women who were psychoanalytically oriented psychiatrists in the 1970s. That’s when the feminist movement encouraged women to tell their stories of abuse. Suddenly women were speaking the unspeakable about incest and sexual discrimination. Some wanted to see a therapist, but only a woman. For those who chose me, I witnessed their personal agonies. What an education it was for me.

Serendipitously, my analytic candidacy began not only at the same time as the ‘70s feminist movement but also just when Heinz Kohut published The Analysis of the Self (1971). I could see that his work was relevant to ethics.

In the ‘80s, Dr. Bernard Rubin, an analyst/scholar, asked me to participate in an ethics hearing at the Chicago Institute because he needed a woman analyst. Since serving on that panel, there was no turn in back. To my utter surprise, ethics and psychoanalysis became my calling. In time, the Chicago Institute became the first American Institute that had a required first year course in ethics. Bernie Rubin and I taught that course for ten years. My ‘70s consciousness raising experiences while I was in medical school had already alerted me to the sexism in our culture, but ironically that Zeitgeist offered me professional opportunities specifically because I was a woman therapist.

Unlike in medicine, free association and confidentiality are essential for analysis to work. The analytic frame was meant to create and stand for, both practically and symbolically, a therapeutic structure with clear and safe boundaries in which the process of therapy unfolds. The establishment of the frame is an integral part of the process itself. Our patients require a trusting relationship where they can freely associate in a safe environment that will never be shared. Analysts question whether we can ensure our patients’ privacy yet still use their clinical material in writing and teaching. Many analytic authors say the solution is to receive the patient’s consent. However, I believe it is still a quagmire to obtain transference-free informed consent from our patients.

I had been calmly weathering the issue of teaching clinical material; suddenly the tornado of cyberspace blew in. Unimaginable new exposures abound for both the patient and analyst. Yet we’re continuing to practice a profession that is all about privacy. What a paradox. As analysts, it is now incumbent upon us to em-

Page 181

brace technology whether we like it or not because our patients rely on it. There is no turning back. For many therapeutic dyads, the web stretches the old rules; some stretching is positive, but some can be disastrous.

I found the perspective of elasticity of technique useful as I confronted social media. I know that with our ever-widening theoretical scope, one size cyber-theory does not fit all. The uniqueness of each member of the therapeutic dyad has to be respected. Our policies require thoughtful therapist empathy when she is negotiating with her patient’s specifics.

Analysts focusing on a co-constructed field become more likely to express their subjectivity. But should they do it on the Internet? This responsiveness should be restricted to the patient’s needs, but how does a therapist do this in cyberspace? Some patients email their dreams to their analyst, lest they forget them by session time. Certainly, this is not a secure medium. Communication is no longer limited to the therapeutic hour.

In 2017, an attorney and I taught an ethics and cyberspace workshop. The attorney participated because there are still unanswered questions that sometimes require legal expertise. We began that workshop hoping the therapists there would share clinical problems. Indeed, they did. In fact, I was unable to finish my presentation, as there were so many issues that the audience brought up. Many involved texting and emailing patients. I recommended that therapists should establish a social media policy about texting, emailing, and Facebook. Will therapist and patient communicate between sessions? How? Should therapists charge for their responding time? For many therapists on Facebook, that platform became onerous. For example, if a therapist happened to find her adolescent patient bullying on Facebook, must she report? To whom? All in all, it is best if these issues are addressed up front in one’s therapeutic contract.

In addition, let us consider the problems of therapist exposure on the web. Accessibility to published material has been radically transformed. Now a current or former patient can simply Google one’s therapist and potentially recognize herself in the text of any publication. Confidentiality (even with disguise) is being challenged again. At the January 2017 meeting of the American Psychoanalytic Association, writing about patients was discussed. One senior analyst spoke about her belief that one should never ask

Page 182

her analysand for permission to publish. That analyst believes it inevitably contaminates the process. I am ambivalent about this since we do need to teach, but it seems unethical not to ask one’s patient.

The practicing therapist today may feel violated, invaded, and exposed in other ways. Search engines have radically changed this and other aspects of analytic anonymity. Now a current or former patient can find out details about where their therapists may be speaking, staying, and what they may be doing. What a therapist paid for her home can be learned by accessing property-tax documents. Also available is the extent of political contributions, even the genealogy of the therapist’s family. There are no therapist secrets anymore.

Aisha Abbasi’s The Rupture of Serenity (2014) is a moving account of her analytic patients’ intrusions via the web into her personal life. This had to do with her older child being transgendered. This public exposure of an analyst’s family life occurred when Abbasi had been an analyst for 18 years. One can imagine how a patient’s discussion of such personal information can challenge even a seasoned analyst. When an analyst brings up the patient’s intrusiveness as a therapeutic issue, the patient may well respond, “But everyone Googles.” It requires tact and experience to consider this an enactment without the patient feeling unfairly accused and there being an ensuing therapeutic impasse.

Next, I will turn to the ethical issues of boundary violations. The prevalence of boundary violations among mental health practitioners is difficult to document although there clearly is an unacceptably high incidence rate of erotic contact. Some suggest that as therapists age and gain more experience, ethical judgment, rather than improving, diminishes and falls below previously held standards. A higher rate of male therapists appears to engage in violations than females; however, statistics are suspect because women patients often report their male violators but interestingly, women patients seldom report their women violators. Clearly, I know there is insufficient research on female/female therapist patient dyads. Some attribute the lack of research on this particular pairing to cultural factors involving the idealization of motherhood and Freud’s legacy that viewed women as sexually passive. Additionally, I wonder if the failure of women to report is because women patients have predominantly different transferences to their women abusers. Is the power differential more of a factor when reporting men?

Page 183

There are many possibilities.

For almost ten years I had the good fortune of participating in a committee of the American Psychoanalytic Association, which was formed in order to establish a curriculum on boundaries. We found that every institute has had a violation. For many analytic communities, after a boundary violation occurs, there is a split. Some are enraged at the perpetrator and are averse to rehabilitation. In addition to the violation of a patient, the term “violation” takes on a double meaning, because there has also been a violation of the “family,” i.e., the psychoanalytic community. Some colleagues may worry they were complicit in some way because they saw problems but did not speak up. The “violator” then becomes the ultimate “other”—different from the rest of us. The judgmental ring of boundary violator may serve an unconscious purpose for all of us: it may help distance us from them, as well as the violence done to our ideals. What underlies this community enactment about boundary violations is important (Glen Gabbard, “The Group as Complicit in Boundary Violations,” Journal of American Psychoanalytic, 2016, 375). Gabbard recommends that we not dwell exclusively on the dark side of turning against our colleagues, rejecting or banishing them often for reasons related to repudiation, disavowal, and evacuation of our own shame. The late Muriel Dimen recommended that there are benefits of trying to think this “unthinkable” in our analytic groups. She believed this can have a prophylactic effect on the incidence of sexual transgressing. She wrote, “As long as the routine presence of sexual boundary violations in psychoanalysis is dissociated, the field needs to live in fear of being discredited” (Muriel Dimen, Journal of American Psychoanalytic, 2016, 370).

As an analytic candidate in my 20s, I had been assigned a training analyst, a woman. As I look back now, that classical analyst helped me a bit with my grandiosity and rigidities. I already knew I was no saint, but back then I was only beginning to tolerate and accept some of my human vulnerabilities. Even after my first analysis, I was still quite judgmental in my thinking. Now I know that what is acceptable is in the eye of the beholder. Ultimately, the way one sees the world, how one matures, and how one’s theories change are just as important as the influence of the actual ethical code. Analysts’ preferred ways of thinking and working are based largely on a complex combination of our early years, personal and intellectual tastes, and identifications with our analysts and

Page 184

teachers.

Over time I matured, as did clinical theory. In my 20s, I did not yet recognize how my subjectivity was indeed an important factor in treatment. Of course, we intellectually know therapists, even analysts, have vulnerabilities when considering the rules. When I was younger, I absolutely knew about following the law. There could be no uncertainty. One was either ethical or not, black or white. I believed I would never be tempted. Not until I chose my second analyst in my 40s was I ready to own more of my own vulnerabilities and disavowals. Then I was at a different adult phase, approaching the age at which my mother died. I had two adolescent sons who could make me feel a confusing lack of cohesion in novel ways. I could see my own rigidities and narcissistic needs played out with my boys. Owning my vulnerabilities at this stressful time, I could imagine, there but for the grace of God, even I could have slid down that slope. Recognizing the humanity in all of us, I could appreciate how a therapist can use splitting to misbehave at times of stress.

Moreover, not all violators are the same. I had an unexpected exposure to one who was a predator. I was chairperson of a psychiatric state ethics hearing. The victim, Barbara Noel, wrote her amazing account of abuse in her book, You Must Be Dreaming (1992). Remarkably, she was not the only complainant against her analyst. There were two other patients who testified against him and his sexual violations. The analyst, Jules Masserman, was a leading internationally-known aging male analyst/predator. After that experience, I began to think that no analyst, even if accomplished and famous, is beyond becoming a violator.

Unlike that predator, I know of two male colleagues who fell in love with their patients and had sexual relations with them. They were the lovesick, one-time violators who eventually came to feel remorseful and sought psychological help for their patient, as well as themselves. These troubled analysts asked me to help their patients. I did and was able to treat these traumatized women who with great difficulties eventually recovered from these professional betrayals. They taught me that there were usual warning signals before erotic contact began. Trouble could be averted, if a therapist were alerted to these cautionary flashing lights, such as arranging a later, unusual session hour; inappropriate self-disclosure; initiating contact outside of session time; and having erotic fantasies about the patient. My advice: if in doubt, consult.

Page 185

Over time, I have altered my initial position about the truly shame-filled, lovesick boundary violator. I believe they can be rehabilitated through analysis and may return to work with close supervision. I came to this position after participating in a ten-year study group led by Arnold Goldberg, which resulted in the publication of a case book called Errant Selves (2000). The book explores how a person with a behavior disorder has one moral sector but at times, when under stress and unable to tolerate painful affects, the person can split or disavow the healthy but weak sector and misbehave in a way that would ordinarily be unacceptable to oneself. A successful analysis involves healing the split within these vulnerable patients. Treatment is lengthy but possible. In order to successfully treat a therapist with a behavior disorder who has misbehaved toward a patient, the analyst, without judgment, should be able to imagine misbehaving similarly toward one of the analyst’s own patients. For an analyst, even one who teaches ethics, morality can have no place in these analyses. She should neither condemn nor endorse the behavior. She analyzes and interprets for eventual repair.

When the American Psychiatric Association asked me to represent them on an Oprah Winfrey show about violators, I did so, and I pleaded for considering that some offending therapists can be rehabilitated. Although I did not persuade Oprah, my belief in rehabilitation was partly because of what I’m about to tell you now: I had the experience of treating three women therapist violators. Two had begun living with their former women patients, and one woman had a sexual relationship with her male patient. None was an analyst. One was a social worker, one a psychologist, and one a psychiatrist; so it was not a question of their training in any one discipline that led them astray. All three deeply regretted and suffered from their misbehavior. I presented a paper several times to professional groups about the analyses of two of these women and how they have been rehabilitated.

After each of these presentations, women approached me afterwards. They wanted to privately tell of women therapist violators they knew about. None of these victim patients had ever reported. I mention this because in all psychological professions women are now the majority. The risks of lovesick violations for women therapists needs to be discussed.

Moving now to my last ethical topic, I will continue my focus on safe-guarding the public and the profession as I consider the

Page 186

aging analyst. The integrity of our profession relies on analysts’ competence. As I age, I ask, “What is the precise moment when aging scholars have peaked?” (“The Philosophy of Feelings,” The New Yorker, July 25, 2014). I similarly wonder when the precise moment is at which an analyst should consider retirement.

In the past decade, I’ve seen so many analysts employing overt denial about their competence. Some were beloved friends, terminally ill, who died while they were still actively involved in practice. Any advice I gently offered went unheeded. Some of their patients knew, but many did not; these patients were left adrift and suffered from iatrogenic traumas. Was I complicit because I did not do more? I hope to inspire older therapists not to wait until impairment is apparent to everyone else. As yet there are no institutional rules, but psychoanalytic assistance committees are tackling this problem. So far, the best book on this subject is entitled The Empty Couch: Taboo of Ageing and Retirement (Gabriele Junkers, 2014)

We all intellectually know the unpredictability of every life; we never know what is going to happen before it happens. We know that cognitive impairment is a process seldom recognized by the individual. Emphasizing the complex relationship each of us has with temporality, there is a deep sorrow involved in therapists saying goodbye. But as a group, do analysts disavow the inevitability of deterioration and death? We are living and working longer. Each therapist must come to grips with evaluating her capacities.

Euphemistically, some authors refer to this age as the third chapter. Personally I favor the new word offered by some gerontologists: renewment. This is a combination of retirement and renewal, an alternative to how negatively therapists are accustomed to viewing retirement. Creativity and meaningful involvements can continue in renewment, after analysts close their practices. The Chicago Institute for Psychoanalysis is planning a study group for retiring analysts considering renewment.

Due to my involvement with ethical issues and my experience in seeing analysts who continued working too long, I have decided to retire from clinical practice on my 80^th birthday, and I have informed my friends and patients. There is also a personal side to this decision. No doubt my experience of never being able to say goodbye to my mother, who died when I was an adolescent,

Page 187

has informed my wish that my patients and I all have the ability to say goodbye and terminate. Relinquishing my clinical practice relies on my acceptance of aging. I am also influenced by Kohut’s view that wisdom includes “the emotional acceptance of the transience of individual existence” (The Analysis of the Self, 1971, 327).

I believe accepting our transience allows us to see the beauty of now. We recognize the wisdom of our patients as they have had the capacity to pull and probe us, so inevitably we analysts have changed. It is our human need to create and re-create a sense of purpose and hope, and working analytically with patients offers a special depth of insight. It is hard for most to relinquish the meaningful work we do, yet it is important to do so before it is too late.

Page 188