To Treat or To Teach–That is the Question

TO TREAT OR TO TEACH—THAT IS THE QUESTION

My research indicates that at many group training institutes across the country, there exists a conflict of interest between the organizations’ need to treat and the need to train. Independent of theoretical orientation and the personalities of leaders, abuses of power often occur when the boundary is blurred between therapy and not therapy. The need to treat is clinical and the need to teach is educational. To combine both under the same roof contaminates both. Training institutes can’t have it both ways because there are both ethical and clinical consequences to this blurring of boundaries. While this axiom applies to analytic institutes for individual psychotherapy as well for institutes for analytic group therapy, the probability of treatment contamination is exponentially greater for analytic group institutes because of the increased likelihood of many different types of combinations and permutations for blurred boundaries in the group setting.

Alterations of the frame always have costs. By frame I mean the nature of the relationships between group leaders and group trainee/group patients and the nature of the relationships between the trainees themselves. THE MANNER IN WHICH MEMBERS KNOW THE LEADER AND WHAT THEY KNOW AND THE MANNER IN WHICH THEY KNOW EACH OTHER AND WHAT THEY KNOW ALL HAVE A PROFOUND IMPACT ON THE COURSE AND ON THE OUTCOME OF THE TREATMENT. This specifically refers to dual relationships that exist between leaders and members and between the members themselves. That is, group therapy leaders often double as supervisors, teachers, administrators, colleagues and even friends of the patient/trainees and patient trainees are often simultaneously fellow supervisees, colleagues, friends and even relatives to each other. Despite the treatment directive to ‘say everything’, it is political suicide to do so when there is outside the treatment group contact. This constitutes a double bind for patient/trainees. They are damned if they do and damned if they don’t. I have come to the ironic conclusion that the group treatment of group therapists may be the most compromised treatment of all. Confidentiality is breached and the transference is diluted at best, and worse it is contaminated, when TREATMENT AND TRAINING TAKE PLACE UNDER THE SAME ROOF.

An ethical dilemma exists because there is no privacy if members have outside the group contact with the leader and with each other. This can lead to ‘looping’ where confidential information shared in one context comes back to haunt group members in another setting. Further, the transference is compromised because it is impossible to discern accurate reactions, to the leader and to other group members, from distortion (as transference implies) when people have real life relationships outside the group. It is the ‘as if’ quality of group therapy relationships that gives this modality its healing power. Without the assurance of a secure frame, where members are anonymous to each other outside the group and where members have only a clean fee for service relationship with the leader, it is not possible to distinguish transference from reality.

This is crazy-making. Gaslighting can occur when group members’ perceptions are invalidated by the group and the leader. 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 his 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 encourage and support the open airing of the untoward consequences of treatment and teaching under the same roof.

It seems to me that this dilemma is unresolvable as long as training institutes formulate their requirement about the trainees’ own treatment under the assumption that the institute’s brand of group therapy is the best one in the profession that is worth studying. This type of arrogant and narcissistic supposition insures the intransience of a conflict of interest within these organizations. Even if the underlying postulation were true, patient/trainees would invariably get caught in the double-bind. No matter how excellent the theory and practice of any method of psychotherapy, the insistence that trainees seek therapy from within the institute confounds the treatment.

I believe the only possible resolution would be for national professional organizations such as the American Group Psychotherapy Association, the American Psychological Association and the National Association of Social Workers, to come together and take a clear unified public stance, insisting that trainees seek treatment outside of their training program, with unaffiliated but nevertheless competent clinicians. This is of utmost importance not only for the treatment of patient/trainees but for the general public of group members as well. When student/trainees receive treatment and training in a compromised milieu, they tend to pass this boundary-less environment onto the groups in their own practices. My research has shown that some of these group leaders/trainees have engaged in complicated extra-treatment relationships such as using group members as accountants, valets, dog walkers, jewelers, travel agents, medical doctors and dentists, chauffeurs and even office painters. In fact, one clinician told me that he believed this arrangement was acceptable as long as he paid the patient/painter the ‘going rate’. While these boundary violations are a far cry from engaging in sexual contact with patients, they may still produce iatrogenic treatment reactions, like anxiety and depression, in members that feel gratified to have been granted special status with their therapists when in reality they have had their dependency needs exploited.