Hello All: For those of you that will be attending my Aurora presentation, I have taken an excerpt from Chapter 5 of my book, “Emotional Incest in Group Psychotherapy—A Conspiracy of Silence” that I think is particularly relevant to clinicians who work with an inpatient population.  Please read this blog before we meet on May 16th and make note of any thoughts and reactions that you have to this material.  We’ll discuss this blog during our time together.   – Dr. Pepper

CHAPTER 5: THE SEVEN DANGERS OF BLURRED OF BOUNDARIES IN GROUP THERAPY

It never ceases to amaze me when I witness, hear about, or read accounts of bright, experienced, psychologically sophisticated group leaders who don’t see how the blurring of boundaries between therapy and not therapy compromise the treatment. Ethical clinicians, as well as unethical ones, both suffer this blind spot, as we have seen and shall continue to see over and again.

Michael Lewis, writing in another context, where he tries to make sense of the factors that cause panic in the stock market; said: “You cannot really see a thing unless you know what you are looking for” (Lewis, 2009).   This applies to the subject of blurred boundaries in group therapy as well. Take the matter of confidentiality and gossip in group, for example. In an article about gossiping in group psychotherapy, Gans (2014), notes :

“Gossip would appear to be the opposite of what takes place in a therapy group…therapy groups, with their boundary and confidentiality agreements, seek to create feelings of safety and trust…gossip, especially malicious gossip, creates mistrust, violates boundaries, harms reputations, and avoids, person-to-person exchange” (p.7)

After having said this, he simply drops a discussion of the connection between blurred boundaries, gossip and negative treatment reactions. In fact, there is only one paragraph in the article that is devoted to the subject of gossip and boundary violations.

In a secure frame environment, gossiping cannot really occur.   Since members are

anonymous to each other outside the group, and there isn’t any social contact, no real life harm can come to members if the group talks about them behind their back, even when they are absent.

However, it is a different story if members have dual relationships with each other in which case outside the group gossiping can have serious consequences, and is in fact, a violation of confidentiality. Although he doesn’t attend to it, there is a vignette in Gans’ article that looks to me like a place where this may have occurred. I’ll have more to say about it a bit later in this chapter. But for now, let’s take a step back and look at the bigger picture of confidentiality in analytic group therapy.

  • BREACHES OF CONFIDENTIALITY

In a previous article, I wrote:

“One of the basic principles for the practice of ethical analytic group psychotherapy is confidentiality. Most group practitioners would agree that this is a cornerstone of the work. In fact, the Code of Ethics for the American Group Psychotherapy Association includes a section on confidentiality (AGPA, 1999). Without the assurance of   complete privacy, and that all participants agree that nothing leaves the room, then security for the frame of treatment could not exist.(Pepper, 2004a, p.103).

However, as Philips (2013) has noted, confidentiality like autonomy is never absolute (p.4), even in a secure frame environment. My own experience supports this observation.

For example, one night, a woman in one of my groups, spoke about a job interview that she had at a prestigious firm. A male group member, with a long history of fluid ego boundaries, who also happened to be looking for a job, and coincidentally at the same firm, turned to her at the next group meeting and told her that “her name had come up during the week”.   Shocked, she asked what he was talking about. He said that in his own job search he had spoken with a recruiter at that firm and mentioned that a friend of his had recently interviewed there. Since he didn’t know her last name, he used her first name and the position that she was applying for. The recruiter recognized the description and said:” Oh, you mean….” and then said her full name.

She was furious with him for violating confidentiality and she turned to me and threatened:” I no longer feel safe here…and if you don’t remove him from the group, I’m leaving”. While I acknowledged her right to feel angry about his breach of privacy, I asked her why her reaction was so extreme. Her response was somewhat paranoid. She feared that she would not get the job if the recruiter associated her with this other member, whom she disdained him and thought was “a loser”.

He was defensive and incredulous. He was not at all able to take her reaction seriously and maintained that he hadn’t done anything wrong. He said that anyone in the similar situation would have done the same. In his mind, he was right, and she was wrong and that was that. Here again was a case of a fellow who had no idea how he came across in relationships.   He was unable or unwilling to look at his part. Had he allowed it, group could have helped him with this insensitivity to the feelings of others.

This bull headed attitude reflected the very same attitude that got him into trouble in his real life relationships, I supported his honesty in telling the group the truth about what he had done. My support fell on deaf ears; however, he didn’t see the damage he had done to his own credibility in the group and how it related to his difficulties in his personal life. I told him that if he believed that the key to successful relationships was to determine who was right and who was wrong in any conflict, then he was doomed to a rather bumpy ride in life. To him, the whole thing was no big deal. He didn’t get it. Even though, he was aware of the rule that everything that goes on in the room stays in the room, he didn’t understand why it was important. And he is not alone with this.   Many group members do not abide by the rule of group privacy even if the need for it is explained to them, but it is not only some group members who don’t see the point. There are those who should know better but don’t.

For example, I received a call from a representative of a nascent training institute established around the teachings of a brilliant, charismatic leader. At that time, I was a student of his in a private training group.   The institute was sponsoring a fund raising drive and was soliciting money from anyone associated with the leader. I asked how they got my name. The caller said that she had been given a list of potential donors, derived in part from the leader’s practice. Then it got even worse. I listened in amazement and shock as she told me that the amount donated would determine how my name would appear in the institute’s fund-raising drive journal: student contributor, donor, sponsor and benefactor!

This contact list contained the names and phone numbers of the leader’s patients and students!

I was stunned by this flagrant violation of confidentiality and told the leader so, at the next group meeting.  But he didn’t get it. His defense was that since he didn’t personally make the calls then no harm had been done. The thorny issue of confidentiality can even be a confusing one to grasp for professional psychotherapists who write about their clinician experiences. The following is a short article that I wrote on the subject (Pepper, 2014).

As an author of numerous articles on boundaries, I have often fretted (along with other writers on psychotherapy) over the challenge of using clinical material while protecting confidentiality of the patients. Some of us have met this task with mixed results (Pepper, 2014).

Once again I return to the work of George Weinberg (1993), who seems particularly challenged at adhering to his own principled philosophy on protecting his patient’s confidentiality. In Nearer to the Heart’s Desire, a collection of case vignettes, he writes in the preface that: “All names, physical descriptions, places, times of occurrence and identifiable events have been changed. Obviously my patients have the right to absolute confidentiality” (1993, p. vii).

However, in the chapter entitled “Tennis, Anyone?” the story of a deeply troubled female professional tennis player, Weinberg (1993) disguises her identity only to provide the reader with the real full names of other women that she played with and against, obviously revealing his patient’s identity to anyone knowledgeable about tennis, or inclined to look up the matches in which she played! After reading this chapter I couldn’t help but wonder why no one picked up this glaring faux pas before publication. Could it be that there is confusion as to what constitutes boundaries and confidentiality in writing about patients?

As complicated as it is writing about individual psychotherapy patients, it is even more complicated when writing about group therapy. Obviously, the ethical writer disguises identities, but sometimes members recognize themselves anyway, as Stone (2014) also points out. And even if the injury doesn’t rise to the level of an ethical violation (or even worse, libel), damage can be done.

In one case from my own writing of clinical experience, a middle-aged female group member was able to identify herself in an article that I had published about boundaries in group. She confronted me in the group, and told me in front of the other members that she felt angry, hurt, and betrayed by me. The group rallied around her, supported and protected her. Some worried that perhaps they weren’t safe with me, and that one day I could do the same thing to them. It was a mess. I bit my tongue when I felt the urge to get defensive. I sat silently as it played out. Even though I had been scrupulous in hiding critical identifying facts, she figured out whom I was talking about. And just when I thought it all might turn into an ugly group revolt, she said something that shifted the whole mood in the room.

She told the group that what had offended her most was that I had referred to her in the article as “middle-aged.” The group erupted in hilarious laughter. We moved on, and she moved on. She had had a strong attachment to me, and over the time we worked together there was much more good than bad. She was able to forgive me and let it go.

In retrospect, one factor that seemed to have played a significant role in defusing the potential for greater harm here was that the group took place in a secure frame environment. Members were known to each other only on a first-name basis; there was no contact outside the group. I believe that anonymity and safety were preserved here because “looping” could not occur. Whatever happened in group stayed in the group. No part of it could come back to haunt her in her real life.

Both examples have at least one thing in common, aside from their manifest intention of furthering professional knowledge. They both reflect, to some extent, the author’s acting out of counter-transferential feelings toward the patients in question. Stone’s final reminder seems apt here: “If you wish to present clinical material, you will be well served to explain the purpose of your presentation.” Apparently, there may be both conscious and unconscious motives for doing so.

Could it be that Weinberg’s decision to disclose the identities of his patient’s famous colleagues was an act of self-aggrandizement? Was his unconscious goal to bask in the glow of his patient’s celebrity status? Who knows? As for me, I may have put angry feelings into play in an attempt to sublimate them by writing about having felt intruded upon. Has the integrity of our presentations been compromised as a result? (Pepper, 2014).

In general, there may be several reasons why some people cannot maintain confidentiality. First, there is secondary gain gratification derived from gossiping, as Gans reports:“ one motive in social comparison is the maintenance of self-esteem” (Gans, 2014,p.8) People may simply like to talk about the ‘mishagosh’ (craziness) of others. This may be done, perhaps, in an effort to place their own troubles into a perspective, allowing them to feel comparatively normal.   As a result, group members do not always understand the necessity of   complete privacy of meetings. Second, there may be a tendency to confuse   talking outside of group about the feelings and issues churned up, without necessarily revealing the details of the sessions and the identities of members. Consequently, there can be a lack of awareness of the potential untoward impact of this seepage on the treatment. The intensity of group meetings may be too much for some members to contain and so   leakage occurs. While the ability to maintain appropriate boundaries is a complicated, and perhaps, a lifelong one to master, the clinical consequences of a lack of confidentiality are immediately apparent.   At the very least, talking about group outside the treatment dilutes its power. For this reason, many analytically oriented group therapists have a rule that prohibits any outside social contact (Pepper, 2004a).

However, the intrusion of managed health care has added a major complication to the matter of patient privacy in all treatment modalities (SEE Giles, 1993). Yet, even without third party interference, the issue of confidentiality is quite complex in a group treatment setting. The very nature of   group, with the sheer number of   participants and all the possible permutations and combinations for boundary crossings, virtually insures the inevitability of violations of privacy.

This is not to suggest that all group therapists deliberately mislead members when informing them about the rules about confidentiality. As ethical practitioners, most do not want the group experience to harm participants. However, there is no way that a leader can protect the complete secrecy of group meetings. In fact, there may be circumstances in which protection is not warranted. In one famous case, for example, a man attending an AA meeting was arrested when a group member reported him to the authorities after he had shared in the group that he had   killed someone.

Still, even under less dramatic circumstances, total privacy is not assured in group. While full anonymity is   an ideal to which members and leaders may aspire, it is seldom attained. Some professional organizations recognize this fact and refer to it in their code of ethics. For example, the Clinical Social Work Federation’s code of ethics states: “clinical social workers treating couples, families and groups seek agreement among the parties involved regarding each individual’s right to confidentiality… clients involved in this type of treatment should, however, be informed that the clinical social worker cannot guarantee that all participants will honor their agreement to maintain confidentiality” (CSWF, 1997,p.8.)

Just as parents cannot save their children from all the dangers of the world, group therapists are limited in their ability to shield members from all untoward occurrences in group, including violations of confidentiality.   Group leaders   need to acknowledge this reality to prospective members during the screening interview. For example, when I offered a patient the opportunity to join one of my treatment groups, he expressed doubts. He said that previously he had been in a group where members violated each other’s privacy. As a result, he was reluctant to participate in group therapy again.   I told him that his concern was a valid one and that   a totally sheltered environment could not be guaranteed with 100% certainty (Pepper, 2004a).

Further, there may be some treatment situations in which confidentiality is virtually impossible to keep, even if all participants agree in principle to maintain it. This can occur when blurred boundaries are built into the system. Under certain conditions, breaches of privacy are an intrinsic part of the social fabric of the group as in the case of inpatient psychotherapy groups, groups   run in small towns, or in many group training institutes across the country where dual relationships exist and where looping, another danger to be discussed next, may occur. At times, the peril of breaches of confidentiality can reach outrageous proportions where the member’s right to privacy is all but obliterated.

For example, a colleague asked my opinion on a predicament that she was in. Her group supervisor put my colleague’s own patient, also a practicing group leader, into the same supervision group that she was in. Understandably, she felt very uncomfortable about the prospect of sharing personal information in front of her own patient. However, my colleague admitted that she was so financially dependent upon the leader, who was source of referrals, that she colluded with the leader against herself and stayed in this crazy arrangement. She had finally had enough when she began to experience anxiety and depression every time she went to group and wanted to leave it but feared that in doing so she would ”burn her bridges”. She was apprehensive about alienating the “mother-feeder” and losing the leader’s approbation. She wanted to know what I thought she should do. I asked her if she were so desperate for referrals that she would be willing to trade her mental health, and that of her patient, for money and stay in this exploitative, but financially lucrative relationship. She left the group soon thereafter (Pepper, 2014).

My colleague’s discomfort and anxiety were directly related to the behavior of the group supervisor, who put my colleague in the untenable position of having a social relationship with her own patient. For her part, my colleague’s own neediness had compromised her good judgment and she stayed until she couldn’t take it anymore.

For the leader’s part, his sense of omnipotence, that he could bend the rules without any consequence and his greed to feed his own supervisory practice, combined to blind him from seeing that he had created an emotionally incestuous relationship between my colleague and her patient while simultaneously creating a pathologically dependent and an emotionally abusive relationship between my colleague and himself.

I have come to the ironic conclusion that the lack of confidentiality in the group leaders’ own treatment and training may be the most compromised treatment of all! Once again, the following vignette was first published from the perspective of a third person observer (Pepper, 2004a).

Years ago, I was a supervision group with a well-known group leader. On one occasion, I complained in group about my individual supervisor, who had been excessively harsh and critical of my handling of a case. The senior leader proceeded to tell me in front of the entire group that he knew my individual supervisor and had had a professional relationship with him. The leader went on to say that my individual supervisor was actually his (the senior leader’s) patient in a therapy group. The senior leader explained that the offending supervisor was actually making progress resolving his issues with narcissism. Although we sat in stunned silence after this egregious breach of confidentiality, nothing was said and the group moved on to another presenter.

  1. LOOPING:

This is similar to a breach of confidentiality in which private information shared in one context is inappropriately revealed in another. Breaches of confidentiality can occur without looping but looping does not occur without a breach of confidentiality. This often happens when group members are in dual relationships with each other.

Goffman (1961) first described this phenomenon in Asylums, his famous study of the social structure of total institutions like prisons, the military and mental hospitals. One part of his work focused on the dynamics of inpatient psychotherapy groups. He observed that looping occurs when patients’ confidential information that they present in treatment groups gets fed back to them in other social contexts. There was no segregation of action for inpatients; behavior in any interaction was available to staff and other to inpatients to be referred back to in other dealings. Since the boundaries were so blurred in the hospital, inpatients had to learn to only reveal information about themselves that would not rebound and harm them in other hospital settings.

Yalom (1985) once stated that he learned through experience that the two most important goals of long-term group psychotherapy—symptom relief and character change—must be modified within the structure of an inpatient unit. While he believed inpatient groups can be therapeutic, their aims must necessarily be more modest due, in part, to the blurred boundaries in that environment (Pepper, 2007, p.21).   Once again, my own experience supports this observation.

Many years ago, as a neophyte group therapist, I ran groups in Upstate New York prisons. One group was at the Bedford Hills Correctional Facility for Women in Katonah. The group consisted of eight to ten prisoners who had been incarcerated for a variety of felonies like drug dealer, embezzlement and even murder. I had been informed of this before starting the group but was not told which prisoners committed which crimes, further I was told not to ask them why they were in jail. I knew that one of the women had murdered her children in a Medea-like attempt at protecting them from her estranged husband who threatened to take them.

For the first several sessions, there was very little talking and the atmosphere was extremely tense. Although we all, save one, sat in a circle, no one wanted to talk about herself, which was completely understandable under the circumstances. “Was there privacy in prison?” they wanted to know. I couldn’t assure them that there would be.

What little talking there was centered on the rules, were they allowed to smoke? Could they take bathroom breaks? The armed guard at the door reminded me that the rules were not mine to make. I decided that I would leave the room during a cigarette break. But even my attempts to get them to talk about why they didn’t want to talk failed to move the group along.

Though groups, in general, are often reluctant to speak, it was more complicated here because no one could be sure if what was said would stay in the room. Looping was clearly a potential danger in prison. I realized very quickly that I would have to adjust my thoughts as to how the group would run. I decided that we should discuss books about interpersonal relationships as a way of engaging them in conversation about feelings without their necessarily having to reveal anything personal. The prison had funds to purchase paperbacks. So between meetings, they read, and we discussed the readings and slowly some personal material emerged.   Throughout the weeks that the group ran, however, the one who sat outside the circle never spoke. She sat off in a corner silently crocheting baby booties. The group was tolerant of her ambivalent attitude toward the meetings. She wanted to be present but she didn’t want to participate. For my part, I couldn’t help but wonder if she were the one.

Nowadays, with the advent of managed health care, matters of privacy are complicated for most groups even outside of prison. Looping and breaches of confidentiality are often closely linked, as the following example reveals. This seems prevalent in the world of group therapy training.

BREACHES OF CONFIDENTIALITY AND LOOPING IN PROFESSIONAL SETTINGS

At some analytic group training institutes, a mad hatter’s tea party- like atmosphere seems to permeate interactions both within the treatment groups and outside of   them. A conspiracy of denial exists within these institutes. Participants do not acknowledge the existence of a contradiction between their belief about confidentiality at the institute and reality. To understand this phenomenon let’s take a step back.

Remember Slater’s (1977) insight, noted in Chapter 2, that organizations as well as individuals, have conflicting needs? When discrepancies exist between belief systems and reality in social systems, then group members unconsciously agree to adjust reality so as to create a sense of harmony between the two. Well, this truism applies here as well, often with disastrous consequences for therapists in training.

In fact, confidentiality at training institutes may be an illusion. In Chapter 1, I referred to an article by Dulchin and Siegal (1982) entitled:” The ambiguity of confidentiality at a psychoanalytic institute” where they observed the evaluation process of therapists in training at a well-known East Coast analytic institute. In an effort to circumscribe the negative impact of dual relationships, the institute developed a policy whereby senior therapists were prohibited from supervising their own patients. However, senior therapists were permitted to treat the supervisees of other senior therapists affiliated with the institute, and all senior therapists attended supervisors’ meetings. As a consequence, the boundary between treatment and supervision remained blurred and there was the potential for breaches of confidentiality. The following vignette is an extreme example of this phenomenon told through the eyes of a group therapist in training.

.           A colleague, “Suzy”, responded to a listserv request that I posted asking group therapists if they would share their experiences in dual relationships. Suzy reported that she had enrolled at a group therapy institute that was headed by “Joannie”, her own women’s group therapy leader. In other words, her group therapist became her boss. After years of treatment, Suzy decided that she wanted to join a group that was coed, to work on her issues with men. She discussed her plans with the leader and the group and went through a termination process, then joined a group led by a male therapist, a man group who was not affiliated with the training institute.

Soon thereafter her advisor at the institute contacted Suzy to say that she had heard that Suzy was no longer in treatment with Joannie. The advisor also knew that Suzy was now in treatment with a man who was not affiliated with the institute. Suzy was stunned and felt betrayed that her confidentiality had been breached. She asked her advisor how she knew all this– to which the advisor replied ominously;” I make it my business to know such things”.

Adding insult to injury, the advisor then told Suzy that since the male therapist was not part of the organization, her time spent in treatment with him could not be counted to fulfill the institute requirement for group treatment hours needed for graduation. Suzy left the meeting in a daze. She was furious, hurt and incredulous. How could this have happened?”- she thought. She was also angry with herself for having been so naïve to have trusted these people.   She questioned the integrity of her director/therapist and her own judgment for having been in treatment with her in the first place.

But if this sordid episode weren’t egregious enough, the injury was compounded at an institute social function when a casual acquaintance approached her and said:” I heard you left your therapist for a man!” My colleague was stunned and was beside herself with rage.

The most troubling aspect of this incident was that until she and I spoke, Suzy blamed herself for having participated in this holy mess. Instead of using this event as a learning experience, she used it to denigrate herself. Suzy was self-critical and now in retrospect, thought that she should have known better than to join her own therapist’s organization. Prior to our conversation, she had begun to doubt herself, minimizing the effect of this incident on her. She had worried that she was making a bigger deal about this than it was.

I reassured Suzy that her feelings of betrayal over these breaches of confidentiality were valid. Although Suzy did bear some responsibility for having placed herself in a compromised treatment environment, and hence, there was an element of truth to her having been naïve to think that her privacy would be respected in this boundary less milieu, this was certainly not all her problem. In fact, I told that she had been traumatized. Suzy had every right to feel rage. She had been betrayed and she had been looped as well.– To disallow treatment hours with the unaffiliated male leader could be seen as punishment for having left treatment with Joannie. How could the advisor have known about Suzy’s new therapy without someone violating her privacy? Suzy felt troubled by all this, she told me that she has been revisiting the occurrence periodically over the years and struggled to reconcile her belief that privacy was a high priority at the institute, when in the reality it wasn’t. Suzy has been reluctant to participate in group therapy, despite the fact that she is a practicing group therapist. Clearly, damage had been done to her.

How many other clinicians have similar stories to tell but who have kept their experience of iatrogenic treatment reactions to themselves? This is the conspiracy of silence. In the following vignette (Pepper, 2004a), the clinician is aware of the danger of looping while in the midst of it. Despite the fact that most everyone knew that people talked about each other’s treatment outside of the therapy groups, members spoke as if this weren’t the case.

A member who was reluctant to reveal personal information in a group in which she had   complicated dual relationships with other members, was told by the group that: ‘ it was okay to share personal information because outside contact was not allowed’!   The implication was, of course, that the information would be kept private. However, when she demurred, the group told her that she had a problem with intimacy. Her unwillingness to trust the group was viewed as a character flaw rather than as an objective view of the boundary-less environment. The leader said nothing, and thereby tacitly supported the group’s attack on her right to privacy in a contaminated boundary environment.

After the session ended, the member left feeling depressed and anxious (personal communication to me). Actually, her concerns were real. She was afraid of being “looped” that is, she feared that revealing very personal information in one context could come back to haunt her in another. The group’s interpretation of her decision not to reveal private information implied that the member’s view of the situation was distorted and that she was responsible for the impasse. There was no acknowledgement of the validity of her realistic concern. In her mind, sharing confidential information in a group, where the treatment frame had been compromised by dual relationships, was fraught with peril.   Consequently, it may have been that her symptoms were iatrogenic in origin rather than transferential.. In fact, the member was gaslit,[1] another of the seven dangers.

I, too have struggled with the prospect of being looped in group therapy (2013) . In the following case, both of us wore two hats.     Apparently, the existence of the rule of confidentiality and the adherence to it within the profession, are two separate things.

I had worked as a staff therapist at a clinic that was affiliated with a training institute and I simultaneously was in group therapy, in a group run by a clinic director. I became interested in working as a supervisor at that clinic. In order to be considered for the position, I agreed to be interviewed by a clinic administrator who was simultaneously one of my own group therapy siblings. The purpose of the meeting was so that the sibling/administrator could determine my fitness for the supervisory position.

At the time, I was experiencing a real-life personal crisis, suffering an emotional breakdown in the form of an agitated depression as a result of the death of my father and the loss of a failing marriage. I was anxious and worried about the prospect of being interviewed by someone who had quite intimate knowledge of my disturbed emotional state and had the power to use that knowledge, from his position of authority, to deny me the position that I sought. I felt paranoid about the prospect of my group therapist/clinic director and my group sibling/clinic administrator conferring about me behind my back. It was clear that my paranoia and anxiety about the interview were related, at least in part, to the compromised and incestuous relationship that I had with both the clinic director and his group sibling at the clinic .I feared that confidential information would be looped back to harm me.

[1] The term comes from the classic movie of the 1940’s, Gaslight. In the film, the husband (Charles Boyer) attempts to drive the wife (Ingrid Bergman) crazy by invalidating her perception of reality, one of the seven dangers to be addressed next.