The hot topics, the ones that garnered the most interest at my Open Session, “The Seven Dangers of Blurred Boundaries in Group Psychotherapy”  at last month’s American Group      Psychotherapy Associations Annual Conference in San Francisco, were  gaslighting, the double bind[1], the controversy about combining treatment and teaching under the same roof,  and the conspiracy of silence. Despite the fact that the session was only one hour long, a passionate and an intense discussion ensued. While many attendees had very positive training and treatment experiences, some did not. There were some participants that were eager to share their concerns and to get feedback about their involvements when the boundary is blurred between therapy and not therapy.

The combining of treatment and training goes all the back to the beginning of the psychoanalytic movement.  Freud disdained academia and created a free standing institute where treatment and training took place under the same roof, with decidedly mixed results.  Perhaps the first case of an iatrogenic treatment reaction as a result of blurred boundaries was that of Victor Tausk, a colleague and rival of Freud.  Tausk committed suicide after Freud refused to treatment him referring him instead to his (Freud’s) protégé, Helene Deutsch, who was also Tausk’s colleague (Pepper, 2014, p.25-26).  Obviously, not all cases of dual relationships are this tragic. Nevertheless, the implications of boundary crossings and boundary violations are worthy of our professional, and at times, personal attention.

Gaslighting occurs when a person’s perception of reality is invalidated.  This is crazy-making. This term comes from the classic movie of the 1940’s, Gaslight,  in which the husband ( Charles Boyer) attempts to drive his wife (Ingrid Bergman) insane  by causing her to question her hold on reality. He wants her out of the way so that he can claim her large inheritance.  She is saved from madness by a handsome stranger (Joseph Cotton) who steps in just in time and proves that her husband’s intentions toward her are malicious.  R.D. Laing was known to have said that the fastest way to drive someone mad is to undermine their view of reality. Just as the wife is saved by an outsider, so too can at risk patients/trainees be spared iatrogenic reactions to compromised training environments when professional organizations, like AGPA, encourage and support the open airing of the untoward consequences of treatment and teaching under the same roof.

For example, one attendee reported that he was gaslighted when he complained to his group therapist/supervisor about the incidence of ‘incestuous’ relationships at his analytic group training institute. The group therapist/supervisor told him that he was delusional. When the attendee threatened to quit the organization he was told that his life would fall apart if he did. This man said;” I did feel psychotic for a long moment whilst my reality was rejected.”  The member/trainee informed me that as a result he suffered iatrogenic symptoms of anxiety and depression (personal communication to me).  Thankfully, this person had strong emotional ties to other professionals outside of his group training institute that validated his perceptions of the contaminated training institute milieu and that supported his decision to leave it. The symptoms subsided after he severed ties with the training institute.  In the following example, the institute attendee was caught in a double bind when she was bullied and intimidated into silence when she questioned the wisdom of both a patient and the patient’s own therapist attending the same AGPA institute.

The term, double bind, refers to the phenomenon where “a damned if you do and a damned if you don’t’ contradictory message prevails in a social system. The concept of the double bind was first used by Gregory Bateson et. al, in his classic article of 1956 entitled, “Toward a Theory of Schizophrenia”,.   Bateson and his team postulated the theory that mental illness develops in an environment that is characterized by clashing, non-verbal communications; to respond to one is to invalidate the other. While other theories of the etiology of schizophrenia abound, and certainly limited to a small range of emotional disturbances, the double bind does precisely  describe the dilemma faced by some patient/trainees who as patients are told to say everything but as students know that doing  so amounts to ‘political suicide’(Kassan, 2010).  The double bind mirrors R.D. Laing’s famous quote about schizophrenic families: “They are playing a game.  They are playing at not playing a game. If I show them I see they are, I shall break the rules and they punish me. I must play their game, of not seeing I see the game”  (Laing, 1970, 1).    After my Open Session, I received this note:

“I wanted to connect with  you a bit at the conference to share a disturbing experience I had, that seems right up you alley of professional focus (which I greatly appreciate, by the way – ethics and boundaries). I was in an institute and at the end of the first day, it emerged that one of the institute participants was the (active, current) therapist of another member of the institute group. It then emerged that this had been known ahead of time, and the therapist in question made no effort to change, etc. and saw no problem with it once it did emerge. This bothered me immensely and it had a terrible, negative effect on the group. When I criticized it at first, there was enormous anger at me from many group members, who advocated for this sort of thing. There was also a blanket criticism of “you should not criticize what we are doing down in Austin” (even though I hadn’t knowingly done so – as the persons in question were from New York). The persons involved, and those defending it, are persons highly associated with the Modern Psychoanalysis school.

On the second day, I had some support in the group, but I feel this was irresponsible, unethical, and potentially harmful to the client involved – and it made for some terrible dynamics in the institute group.  Can you give me any sense of this? I would be very grateful”.

Despite the directive to say everything, this participant was led to question her own feelings and perceptions by the institute leader and the like minded participants of the institute.  A group/think environment prevailed that silenced dissent and shamed anyone that had a legitimate, but differing point of view from the others. That the institute participant felt the  need to defend herself in the communication to me (when she said that she hadn’t knowingly criticized the Austin group’), suggests that she was frightened by the group and felt guilty for having an objection to the incestuous relationships in that institute. While it is well known that some famous analysts have been treated by their own patients, this arrangement is considerably more complicated in the group setting.  Who is the patient here?  Whose needs come first?  And what happens to the group dynamic when a ‘parent’ morphs into a ‘brother’? According to my informant, the effect was adverse. But to my mind, the equally troubling dynamic in this institute was that my informant was intimated and pressured to shut up. (Ironically, the decision to inhibit my informant’s verbalization of negative feelings toward the leader runs counter to the basic tenets of modern analytic theory.) This led to my informant’s experience of an iatrogenic treatment reaction and is an example of the pernicious impact of the conspiracy of silence. In an environment where saying everything is dangerous, at risk members, may regress and decompensate if they passively acquiesce to the unspoken value system of the group.

These scenarios sound an alarm.  Even if these are isolated cases within our profession (which I highly doubt) this matter needs to be publicly addressed. Toward that goal, I recently posted a listserv request on the AGPA website asking for volunteers to serve on a panel, at next year’s Conference,  to discuss on the pros and  the cons of combining treatment and training.  So far, I have received several responses from AGPA members that would like to discuss the cons.  As yet, no one has come forward to address the pros.

 

 

  1. After having submitted the proposal for this Open Session, I uncovered an eighth danger—the double bind.

 

 

References

Bateson, G., Jackson, D. Haley, J. & Weakland, D. (1956), “Toward a theory of schizophrenia”  Behavioral Science 1 (4), p.251-264.

Gabb               Gabbard, G.  & Lester, E.  (1995). Boundaries and boundary violations in psychoanalysis. Washington, D.C.: American Psychiatric Publishing, Inc.

Kass                Kassan, L.D. (2010).   Peer Supervision. London: Jason Aronson.

Laing, R.D. (1970)   Knots. New York: Pantheon

Pepper,  R.S. (2014).  Emotional incest in group psychotherapy—A conspiracy of silence.   Lanham, Maryland: Rowman & Littlefield

 

 

[1] After having submitted the proposal for this Open Session, I covered an eighth danger—the double bind.