by Maja Farrell
After having read the PSYOP Transference Love and Harm by Dawn Devereux, published in the Sep 2016 BACP magazine Therapy Today, (see bottom of page) I felt the need to respond and address the many subtle yet dangerous suggestions dropped by Ms Devereux, in agreement with the Clinic of Boundary Studies.
PSYOP
Psychological operations (PSYOP) are planned operations to convey selected information and indicators to audiences to influence their emotions, motives, and objective reasoning, and ultimately the behaviour of governments, organizations, groups, and individuals.
AIT
Adverse Idealising Transference
Adverse = adjective: adverse, preventing success or development; harmful; unfavourable.
It is the Client's Fault!
No rape victim is ever at fault of being raped, neither is a client ever at fault of being abused or taken advantage of by a health professional. Yet the Clinic of Boundary Studies (CfBS) and perhaps the BACP too, would like us to believe differently. In the eyes of the CfBS a client is not only predisposed to developing a state of mind that creates and encourages abuse by the therapist but the therapist's behaviour is not even abuse, in most cases, it is either love that the client cannot tolerate "If the client is predisposed to developing AIT, they are likely to find it difficult to tolerate the constraints of a time-limited love relationship."or an development of "intense, delusional ideas about the therapist’s actions in the therapy [...] just as a successful therapeutic alliance is forming..."
Let us start at the very first paragraph which was clearly written to set the stage of an actively searching, dare I say aggressive patient who is ruthlessly trying to still his already existing, not-in-reality-grounded-longings which are brought to live by a rather passive therapist whose only mistake it is that he is either loving or successful in creating a therapeutic setting (see above).
Are we encouraged to believe that any abuse at the hands of a therapist is really the client's fault due to his unfavourable transference which is a "potentially harmful side effect" that can rear its ugly head if he is predisposed to AIT.
Within this adverse idealising transference "side -effect" the abuse of the client is not seen for what it is - an acting out from the unethical and often narcissistic therapist - but excused as a reaction from a therapist who has been enticed by a client's wish to cause harm and prevent success.
The Therapeutic Relationship is an Illusion!
If there should be any hope left in the client for the governing body to take his complaint seriously - based on the theory that it takes two to tango meaning anything within the room is co-created by therapist and client - Devereux makes sure she bursts this therapy myth explaining "that there is a type of AIT that develops independent of the therapist, and quickly becomes very negative. This is known variously as malign, malignant, regressive or psychotic transference," (see 1)The client stands no chance, even if he decides to state in a complaint that his behaviour was a result of the therapist's abuse, with help of the CfBS' explanation of an unfavourable and malignant transference reaction the well-meaning, loving therapist has now proof that the client is mentally ill and a dangerous fantasist.
The defense of abusive therapists continues by emphasising that clients' realities are really just based on feelings and beliefs that are not grounded in the present therefore are clearly affecting the person’s judgement and are definitely not connected to the therapist.
The client is not just someone who creates an unfavourable and harmful transference but he is also mad.
Transference is Masking the Real Problem!
To confuse the client, as well as the therapist even more, Devereux suggests that this transference is actually "masking the problems that brought the person into therapy and so masquerades as a cure."Yes, away with the pillar on which psycho-analyis rests, transference is no longer the way into a person's internal world but it is indeed a hindrance - only if the therapist feels out of his depth, of course.
On a serious note, how can transference, no matter how "unfavourable", be masking problems when it yet has to be explored what the unconscious problems of the client are. Sure, the client might have entered therapy because of bereavement but how do we know this loss is not triggering other painful, repressed feelings that were split off?
We do not know! Hence everything about a client's transference is a gift, which, unafraid of her own pain, the therapist can use to get closer to the pain of the client.
Indeed it is true that many clients "spend thousands of pounds on therapy, only to discover that their presenting problems have not been addressed" but this is not due to the transference but rather the therapist's inability to address the transference appropriately so the client can become aware of and understand any resistance to moving forward.
Your Characteristics may let You fall Victim to a Client!
"From our discussions with clients seeking our help, we have noted particular therapist characteristics that appear to be associated with AIT"
Not associate with abusive tendencies, no! Accosiciated with AIT!
Although the author finally begins to mention the therapist, his abuse only happens in conjunction with the client's Adverse Idealising Transference, an unfavourable, harmful and success preventing state of mind.
The Psychopaths
Not surprising then that Devereux puts therapists' characteristics on a continuum that highlights different therapeutic pit falls associated with someone afflicted with AIT; Oh, except of course, for the psychopath, who by default is a planning and conniving manipulator,the only one whose actions really count as abuse - unless the client can't proof he is not suffering from AIT, naturally.
The Lover
But not to worry, those psychopaths can't be many and we would surely recognise them; in any event, they can't possibly be white, middle class, older ladies who offer a "love relationship" and who only overstep boundaries because the client demands it.
"Some therapists in this category do not set out to oˆffer love but respond to the client’s demand that they prove that they care and find themselves breaching boundaries if the client’s demands then escalate and cannot be satisfied."
The Weak One
This therapist cannot resist the harmful lure of the client and just has to take advantage of him/her.
"Then there are the opportunist therapists, who may not set out to exploit the transference but cannot resist doing so when it emerges."
To give us a good picture of the therapist's helplessness when working with such a predisposed-to-madness person the author uses the example of a client holding a piece of glass to her own throat because she had seen another client leave the office. Devereux works hard to show such clients in a light of absolute irrational, dangerous and nonsensical behaviour that exists in a vacuum and has no connection to the therapist's previous behaviour.
The Perfect One
And then we have the therapist who does everything right and because he does everything right, his client becomes delusional and hands in a complaint.
"Therapists who act appropriately but find that the client is predisposed to developing a regressive transference. This is likely to become apparent just when the therapist feels the therapy is going well, and it frequently involves delusional ideas about the therapist’s actions and intentions. It may be impossible for the therapist to resolve the situation because the client’s beliefs are so tenacious. Therapists in this group may find themselves the subject of a complaint, because the client truly believes they have acted inappropriately."
I wonder if all complaints dismissed by counselling organisations rest on this terribly grandiose statement and narcissistic illusion.
Love, Nurture and Nature creates a Mad and Bad Client!
"Clearly there will also be factors that contribute to AIT but are outside the therapist’s control."Devereux's article so far has been about convincing the reader that the helpless therapist is in a no win situation when working with someone predisposed to AIT; everything seems to be outside of the therapist's control. So rather than finally exploring the therapist's role in this unconscious dynamic called AIT, the author lists even more reasons why therapy abuse is definitely down to the client.
Again, the client suffers from an unfavourable and success preventing transference, which demands the therapist to act out of love. Yet even such ethically sound behaviour by the therapist can contribute to the client becoming more harmful and psychotic. Here is the list of triggers that can contribute to the client being taken advantage of, mistreated, rejected, abandoned or abused:
• client’s early developmental experience
• genetic makeup
• neurobiology of the brain
• the therapeutic setting: low lighting, a calm comfortable room, prolonged eye contact
• finding themselves the focus of another’s intense interest may be a unique experience for the client and may be unconsciously associated with a promise of love and nurture.
As it stands, not only is a potential therapy breakdown and abuse woven into the client's innate being but he is also told that therapy cannot help him. Yes, he is indeed so damaged that everything normal like low lighting, a calm comfortable room, prolonged eye contact, finding himself the focus of another’s interest - yes even love - turns him into a harmful, dangerous, psychotic, malignant beast.
We are lead to believe that love will cause hurt to such a client and ultimately end in tragic destruction of everyone around him. I wonder what would reduce the risk of this destruction; perhaps we as therapists need to become colder, more aloof and indifferent before we finally decide to get rid of the client?
Reduce the Risk of AIT - Reduce the Risk of Abuse
The author continues to ask "what can reduce the risk of AIT" therefore still trying to convince the reader that reducing AIT will reduce the possibility of being mistreated or abused by the therapist. What is missing of course is the question "What could reduce the risk of a needful client being abused by a therapist"Further reading shows what is really meant by a "reduction of risk of AIT'.
If the therapist finds, in her assessment of the client, that he has a history of feeling strongly about other people, especially health professionals it may suggest he is not really wanting to heal but is really just "primarily seeking care, not insight into his problems" which in turn means he "holds unrealistic views about what therapy can provide" which brings us back to the client not being anchored in reality.
Perhaps an article about "How to be a good therapy candidate" would be more appropriate, so clients can mold themselves to the needs of the therapist before "therapy" even starts.
Right near the end the author mentions that "the risk of AIT can also be reduced by responding appropriately when clients bring up transference concerns, as AIT is much more likely to occur if the first indications are ignored."
Acknowledging the abused client's blamelessness by mentioning an appropriate response by the therapist is only a smoke screen for the underlying message that this can only reduce the risk of the client becoming unfavourable, harmful, malignant and dangerous.
What is missing yet again is the acknowledgement of the risk of potential abuse by a therapist who is confronted with a regressed client who has become needful and frightened in the transference.
Not all is lost though! What follows next is a list, written by Devereux and approved by the CfBS, of therapist behaviours that can keep the therapist save and therefore reduce the risk of the client's AIT breaking out!
(Just a reminder, those points about to follow are actually boundaries that are part of the therapeutic and ethical framework; boundaries the therapist should practice at all times, not just with clients prone to become mad and bad.
How to reduce the risk of AIT
1. Inform clients
2. Carry out regular reviews
3. Maintain consistent professional boundaries
4. refrain from personal disclosures
5. Refrain from making the client feel special.
6. Be clear that the relationship can only ever be professional.
7. discuss with client in order to work out the best way forward
8. Take it to supervision
9. seek external consultation
10. Take responsibility for any actions
11. Refrain from acting defensively by blame, rejection and sudden rigid boundaries, or terminating the therapy without the agreed notice period.
What really is Transference?
Now that I have dissected and untangled the information within this PSYOP, let us examine what transference really is.Projection
Although the author rightly points out that transference feelings are rooted within (past) relationships to significant others, transference is not a projection as Ms Devereux would like us to believe in her example:
'When a client falls in love with a therapist it is likely to be ‘transference’: the predisposition we all have to transfer onto people in the present experiences and related emotions and unmet longings associated with people from our past. In the initial stages of therapy, such transferences are usually idealising, because clients tend to project onto their therapists the qualities they longed for from their early carers, and so experience them in a particularly positive way."
This is really an example of splitting and projection in which a (very young/early) part of the client splits the needed person (therapist/mother) into good and bad. That way he can experience the therapist/mother as good and doesn't have to become overwhelmed and psychologically stunted by any anxiety that could be evoked by this significant person's "badness" (which is incapable of meeting the baby's needs.)
So, if the client did experience unmet needs in childhood, as suggested by the author, the feelings would not have been positive even though they may have presented as positive to the conscious mind but unconsciously the baby would have experienced anxiety created by the split off and suppressed anxiety of having to trust a caregiver who was potentially dangerous to the baby's psychic or physical life.
Transference
In the transference the same process will be repeated:
Unable to deal with anxiety towards the needed therapist, the client splits this internalised relationship into good and bad. He may now project either goodness or badness onto/into the therapist.
If goodness is projected on the therapist, the badness will remain elsewhere.
What we may see as therapists is a client who seems to idealise us, what is not visible, however, is the split of, unbearable pain.
Hence this "adverse, idealising" behaviour is therefore not based on the client's wanting to have a mother/father/therapist who takes care of him but it is based on his need for safety triggered by the unconscious, transferred fear, an anxiety of the therapist being exactly like the significant other from the past - rejecting, abandoning or abusive. And that is the transference.
Hopefully, seeing transference in this way enables therapists to become aware and hold on to the client's pain (the reason for coming to counselling in the first place!) and keep him in mind as a vulnerable person rather than a manipulating, fearless pursuer who is not only out to prevent a successful therapy but also to cause harm.
Portraying him in such a light and calling this state of anxiety a "honeymoon period", not only fails to acknowledge the enormous amount of fear and terror underneath the client's idealisation but hints that:
a.this is a phase that will naturally come to an end
b. the therapist cannot and does not in any way cause or influence it.
both assumptions are of course wrong and play a huge part in therapy abuse and breakdown.
Transference is not a phase that miraculously appears and then fades away
Yes, we all transfer feelings from the past onto present relationships, but not chaotically and without reason.
For a transference to find a receptor, the therapist must possess a hook, a trigger. This may be the therapist's voice which reminds the client of his father, or a giving and taking away of privileges (such as contact between sessions) which may remind him of his intrusive yet equally withholding mother.
Both examples may trigger feelings from the past which create a lens through which the therapist will be carefully watched.
It is this hook, this trigger that we therapists look for and need to explore with the client. As painful as transference can be for both parties, it is also a gift of the client's unconscious that invites and allows us entry into his internal world.
When Therapists are Unable to Work with Transferential Feelings
Transference will always exist between therapist and client and if it is not made conscious and understood it will have no other choice but hide and lay dormant behind strengthened psychological defenses; because just as the child had to adapt to a parent who was unable to contain his anxieties, so does the client now adapt to an in-the-transference-perceived-as-uncontaining therapist. If we were to look at the client now through the lens of AIT, we would make his biggest fear (and projection) come true - that his feelings are dangerous, harmful and too frightening to be hel[pe]d. We would identify with his projections and ultimately act them out by either abusing or rejecting him.The client would have no other choice but to either leave and take with him his own as well as the therapist's anxiety or stay and become compliant/idealising; a process Alice Miller highlights in Thou Shalt not be Aware: Society's Betrayal of the Child:
Formulations such as "negative therapeutic reaction" or "resentful patients" remind me of the "wicked" (because "willful") child of "poisonous pedagogy," according to which children are always guilty if their parents don't understand them. Yet patients are just as little to blame for our lack of understanding as children for the blows administered by their parents. We owe this incomprehension to our professional training, which can be just as misleading as those "tried and true" principles of our upbringing we have taken over from our parents. [...]
As a result of "poisonous pedagogy" they [clients] are so accustomed to not being understood and frequently even blamed for their fate that they are unable to detect the same situation when it occurs in analysis and will adapt themselves to their new mentor. They will leave analysis having substituted one superego for another.
The Client Needs to Become the Abuser
There is a huge amount of anxiety behind the therapist's need to reject or abuse the client. This anxiety is clearly reflected in the author's need to dismiss the client's transference feelings as either a honeymoon period or AIT - both extremes that are not favourable and need to "fade away".To deal with her anxiety, Devereux minimises such painful realities to a "small number" of people.
"However, for a small but significant number of people, the experience is very different: the idealisation intensifies rather than fades, and the client becomes increasingly consumed with and dependent on thoughts about the therapist."
The therapist becomes the victim while the client has now shifted from a love-struck, harmless because idealising client to a suddenly frightening client "consumed with and dependant on thoughts about the therapist". A client who has now become "adverse" because this independent thing in him, that has no connection to the therapeutic relationship whatsoever, is making it difficult for him to act autonomously. Worse even, this mental defect is now making him dangerous and harmful to his family as he has also lost the ability to think rationally! The client has now turned into an unpredictable abuser!
Is that what CfBS, BACP and other organisations see when such a labelled client hands in his complaint?
"Several hundred people contact the CfBS each year, and a substantial number report lasting harm as a result of AIT. The phenomenon is often discussed within the discourse on erotic transference."
"This accords with the experience of people who contact the CfBS, who usually describe experiences of inadequate parenting, rather than overt abuse."
The author has changed yet again something that started to acknowledge the abuse of the client to something that really is quite dismissive by interpreting it as an "experience of inadequate parenting rather than overt abuse".
Perhaps we should ask ourselves whether clients who feel they have been abused by their therapist (and/or who want to make a complaint) really go through their childhood history with the CfBS and if so, who are these people within the CfBS who "have worked successfully with clients who have a history of dependent/ idealised relationships" ?
Are these the same people who judge whether a client's experience was indeed abuse or just a delusional acting out?
If so, how are these people connected to individual counselling governing bodies that review complaints.
Conclusion
No, hundreds of people are not harmed as a result of AIT; hundreds of people are harmed because a therapist abused his/her power and did not uphold his/her ethical boundaries. The abuse or mistreatment may have been a response to the client's projections or behaviour but it was acted out by the therapist.The client was not abused because he suffered from an 'adverse transference' but because the therapist was unable to deal with her counter-transference appropriately.
Perhaps it would have been more helpful and hopeful for Devereux to explore the therapist's perception and underlying fear of being harmed rather than spending all this time, energy and magazine space trying to formulate a text to convince clients and the public that there should be doubt about who is at fault in a psychotherapy abuse case.
Yet fault is very rarely appointed to the therapist (compare number of therapists called to a hearing to "the several hundred people contacting the CfBS each year"), especially psychoanalytic therapists have many theories that provide cover from possible awareness of client abuse. This ignorance can cause deep trauma to the abused client, especially when governing organisations refuse to take his complaint serious.
Thanks to this article we now know why many, many complaints don't even make it to a hearing -
because the client is at fault! He has created his maltreatment with his transference!
Please stop writing articles about why therapy abuse is the fault of the client and instead offer us therapists and trainees more possibilities to examine our need, desire and longing to abuse, reject and abandon certain clients. This profession needs a non judgmental and truly private setting that is not permeated by the incestuous and intrusive world of (psychoanalytic) counselling and training in the UK.
1
"Although the literature greatly underplays the role of the therapist in AIT, it is important to state that there is a type of AIT that develops independent of the therapist, and quickly becomes very negative. This is known variously as malign, malignant, regressive or psychotic transference,"
The reader expects to read
Although the literature greatly underplays the role of the therapist in
AIT, it is important to state that therapists do play a role in it
Instead we read
Although the literature greatly underplays the role of the therapist in
AIT, it is important to state that therapists do not play a role in it.
© Maja Farrell
The
cliché that people fall in love with their therapist is well
established in the popular imagination and often treated with some
amusement. In reality, what some clients are experiencing is a
potentially harmful side effect of psychotherapy and one that should be
taken far more seriously by the profession.
When
a client falls in love with a therapist it is likely to be
‘transference’: the predisposition we all have to transfer onto people
in the present experiences and related emotions and unmet longings
associated with people from our past. In the initial stages of therapy,
such transferences are usually idealising, because clients tend to
project onto their therapists the qualities they longed for from their
early carers, and so experience them in a particularly positive way.
This can help establish the therapy and the initial intensity usually
fades once the ‘honeymoon’ period of the therapy is over. However, for a
small but significant number of people, the experience is very
different: the idealisation intensifies rather than fades, and the
client becomes increasingly consumed with and dependent on thoughts
about the therapist. This can be immensely disruptive to the client and
to their family, and can lead to adverse consequences, as the client’s
autonomy and capacity to think rationally are typically compromised.
‘I
was like a rabbit caught within blinding headlights. I was uneasy, but
in a childlike way also excited by being so special to a person such as
him. I was very confused, experiencing feelings that I had not felt
before. I can only describe it as like being caught up in an emotional
earthquake.’1
This
article is based on the accounts of people who have had this experience
of adverse idealising transference (AIT) and who have contacted the
Clinic for Boundaries Studies (CfBS), an organisation that helps people
who feel they have been harmed by their experience of psychotherapy or
other professional relationships. Several hundred people contact the
CfBS each year, and a substantial number report lasting harm as a result
of AIT. The phenomenon is often discussed within the discourse on
erotic transference but my emphasis is on the idealising rather than the
erotic aspect; not all clients experience erotic feelings and, even
when they do, these feelings are almost always infantile and sensual
rather than adult and sexual. What is desired is not man but mother.2
This is also why any consequent sexual contact with the therapist is
likely to be experienced as confusing and exploitative.
The
CfBS working definition of AIT is ‘a transference reaction that impacts
on a person, so that over a sustained period their ability to function
in their usual way is adversely impaired’. The effects can last over a
long period of time, as evidenced by the large number of people who
contact the CfBS about an idealising transference that began decades ago
and is still unresolved. It is also evidenced by the many accounts of
transference harm that can be found on the internet (see
www.mentalhelp.net) and in the client literature.3 Members of the public
who have experienced this believe that therapists are not sufficiently
knowledgeable about the phenomenon, or are unaware that their actions
can both cause and exacerbate the problem. Yet the professional
literature does not appear to associate idealising transferences with
serious and lasting harm, which is why I want to share what CfBS has
learnt about AIT.
The
propensity to develop intense feelings for a therapist has been known
about since the earliest days of psychoanalysis and Anna O’s famous
obsession with Freud’s colleague, Breuer. Freud4 used the analogy of a
chemist handling highly explosive materials to describe the potentially
catastrophic consequences when such feelings develop. Freud’s focus,
however, was on the therapist’s experience of the phenomenon, rather
than on the adverse effects on the client. He emphasised the erotic
aspect, and believed that tenacious manifestations of the transference
were a resistance to treatment and an attempt to seek cure through a new
relationship. For this reason, he was clear that such transferences
should be analysed and not reciprocated.
This
view was further developed by Klein and her followers, who proposed
that destructive and aggressive feelings are also present and should be
interpreted, particularly in relation to envy and difficulties in
tolerating the independent existence of the analyst.5 From the 1970s,
following Kohut’s emphasis on the idealising rather than erotic aspect
of the transference,6 a more positive conceptualisation of the
phenomenon began to emerge. Kohut focused on the facilitative aspects of
the transference and insisted that it should not be interpreted but
left to take its course until firmly established. This view was
controversial and attracted criticism, particularly from contemporary
Kleinians. In subsequent years some therapists went further, suggesting
that erotic desire in therapy should be facilitated.7 Our experience is
that this encourages AIT to develop. Client accounts and insightful
blogs on the internet vividly describe the harm that can result. A
particularly extreme example of a toxic mix of cult-like idealisation
and sexualisation in group therapy has recently been described by the
mental health blogger Phil Dore.8
Although
the literature greatly underplays the role of the therapist in AIT, it
is important to state that there is a type of AIT that develops
independent of the therapist, and quickly becomes very negative. This is
known variously as malign, malignant, regressive or psychotic
transference, and was elaborated in particular by Little,9 and more
recently by Hedges.10 It refers to a situation in which people with no
history of psychosis become regressed and develop intense, delusional
ideas about the therapist’s actions in the therapy. Hedges believes that
this is likely to happen just as a successful therapeutic alliance is
forming, because the person’s fear overcomes their desire for
connection.10
Effects of AIT
People
who contact the CfBS about an experience of AIT emphasise in particular
their feeling that they are disempowered. They often compare the
experience to that of a powerful mood-enhancing drug, a religious
experience or an addiction. They often use words such as hypnotic,
enchanting, magical and sublime, and describe striking imaginary
scenarios to illustrate the primacy of the therapist’s position in their
life. For example, one person described being haunted by the image of a
lifeboat with only one space, because she knew she would give it to her
therapist and not her much-loved children.
Although
people often describe the transference as making them feel ‘alive’,
they also describe profound confusion, distress and shame. Retrospective
accounts also often describe feeling in thrall to the therapist and
considerable disruption to social and family life, as the person’s
interest in other previously important relationships diminishes.
‘I
cannot over-emphasize the devastating effect all this had on my husband
and children. I think they could not recognise the person they had
known – a family-orientated wife and mother. It was as if an alien had
invaded my being and I was speaking and behaving in ways that were just
not me. It is difficult after these years to understand the intensity of
my feelings for him and the total subjugation of my will to his.’1
Some of the most common feelings and beliefs that clients describe when AIT is developing are:
believing that a ‘real’ relationship with the therapist would result in deep contentment
feeling that other aspects of life are diminishing in importance, including relationships with friends, a partner or children
feeling that the problems that brought the person into therapy in the first place are no longer important
feeling panic or depression at the thought of the therapy ending.
‘My
feelings for Marion intensified. During the 166 and a half hours a week
when I was not with her, I thought about her constantly. The rest of my
life was dwarfed into insignificance… “Relationship” was no longer an
adequate word to describe what bound us together. In my mind, I was
transported into another world where I existed in a state of rhapsodic
communication with Marion. We did nothing, we said nothing, we just
were.’11
A
transference of this kind clearly affects a person’s judgment and
interferes with their autonomy, leaving them vulnerable to sexual,
emotional and financial exploitation. It also masks the problems that
brought the person into therapy, and so masquerades as a cure. A client
may spend thousands of pounds on therapy, only to discover that their
presenting problems have not been addressed.
‘A
magic trick had been performed on me: in just a few hours of sitting
alone in a room with Paul, a large part of my mind had effectively been
taken over, leaving me with little left to expend on my work, social
life and other parts of normal life.’12
Therapist characteristics and AIT
From
our discussions with clients seeking our help, we have noted particular
therapist characteristics that appear to be associated with AIT. These
characteristics sit along a continuum but fall broadly into five
overlapping categories. They begin, at the most severe end, with the
psychopath who becomes a therapist. This is the ‘unscrupulous therapist’
described in the Foster report,13 who sets out to use transference to
create dependency and then intentionally exploits the client for
emotional, financial or sexual advantage, for years or even decades.
Clients of such therapists often describe being drawn into cold,
humiliating sexual activity, and/or financial and emotional
exploitation, where they are coerced into making self-defeating choices.
These therapists frequently exploit their knowledge of the client’s
developmental vulnerabilities in order to exert maximum power and
control.
Then
there are the opportunist therapists, who may not set out to exploit
the transference but cannot resist doing so when it emerges. They reap
the emotional, financial and/or sexual rewards, and often convince
themselves that the client’s feelings are ‘real’ and that sexual
exploitation is ‘an affair’. They typically have poor professional
boundaries, operate from a narcissistic position and often have
relationship problems themselves, so the client becomes a source of
comfort and validation. Clients of therapists in this category
frequently describe getting into role-reversal situations with them.
The
third category comprises therapists who offer love in the belief that
they can compensate for their client’s history of poor parenting.
Clients often respond with appreciation and idealisation, which
encourages the therapist to continue practising in this way. If the
client is predisposed to developing AIT, they are likely to find it
difficult to tolerate the constraints of a time-limited love
relationship. If they then act out their frustration, it is not uncommon
for therapists to feel justified in terminating the therapy, without
being aware of the part they have played. Some therapists in this
category do not set out to offer love but respond to the client’s demand
that they prove that they care and find themselves breaching boundaries
if the client’s demands then escalate and cannot be satisfied.
‘When
I met Karen I was struck by her warmth and confidence. She said she was
an expert on my condition, that my life would change. I felt elated, as
if I’d been blessed and chosen. We had a special bond, she looked out
for me like nobody had done before… She said she would always be there
for me, and when I questioned “how” she hugged me, fixed her eyes on
mine and said, “Trust me.” This didn’t help. I needed to know how and
this irritated her. I began to be silent during sessions and Karen said I
was trying to sabotage the therapy and didn’t want to get better. She
told me that her other clients improved because they trusted her. At the
next session, when I saw her previous client leave, I experienced a
sudden, visceral feeling of rage. I was drenched in fizzing emotion and
couldn’t think. I went into the room, picked up a glass and smashed it. I
held it to my throat… That was the last time I saw Karen.’14
The
fourth group of therapists refuses to engage with the transference.
They may do little or nothing to encourage the idealisation; when it
emerges they ignore it, or treat it in a pejorative or disapproving
manner. These therapists may feel incompetent, irritated or ashamed that
this situation has arisen, and this produces shame and confusion in the
client. The client then conceals the idealising feelings and they
flourish in silence, until the adverse aspect becomes apparent because
the feelings can no longer be hidden. Sometimes clients of these
therapists simply leave the therapy and then find it impossible to
resolve the transference.
The
fifth and final category, at the far end of the continuum, is
therapists who act appropriately but find that the client is predisposed
to developing a regressive transference. This is likely to become
apparent just when the therapist feels the therapy is going well, and it
frequently involves delusional ideas about the therapist’s actions and
intentions. It may be impossible for the therapist to resolve the
situation because the client’s beliefs are so tenacious. Therapists in
this group may find themselves the subject of a complaint, because the
client truly believes they have acted inappropriately.10 This may also
happen because the therapist cannot deal with the strain and ends the
therapy without the agreed notice period.
Box 1: Therapist actions that contribute to AIT
Encouraging contact from the client between sessions.
Revealing real feelings for the client.
Discussing details of the therapist’s privatel life, and in particular unsatisfactory aspects.
Making it clear that the client is being treated in a different way to other clients.
Self-enhancing disclosures.
Disclosures that imply a unique ‘soulmate’ type relationship between client and therapist.
Offering real love and care and becoming over involved in the practicalities of the client’s life.
Discourse that hints, often in a very subtle way, at a future ‘real’ relationship with the therapist.
Refusing to discuss the transference in an appropriate manner.
Non-therapist factors in AIT
Clearly
there will also be factors that contribute to AIT but are outside the
therapist’s control. These include the client’s early developmental
experience. Kohut6 theorised that the necessary conditions arise if a
mother is unable to attune to the particular needs of her baby, and the
baby is unable to internalise the mother. Little9 similarly associated
the phenomenon with the infant’s poor experience of mothering. Blum15
made particular mention of children who have experienced sexualised
parenting, and Hedges10 proposed that the absence of nurturing in
infancy leaves some people with an insatiable desire for the mother they
never had. This accords with the experience of people who contact the
CfBS, who usually describe experiences of inadequate parenting, rather
than overt abuse. Since not all people who have had inadequate parenting
are predisposed to AIT, it seems likely that constitutional factors
such as genetic makeup and the neurobiology of the brain also play a
part.
The
therapeutic setting may also contribute to AIT. Low lighting, a calm
comfortable room, prolonged eye contact and finding themselves the focus
of another’s intense interest may be a unique experience for the client
and may be unconsciously associated with a promise of love and nurture.
Because the ‘love’ is one way, it tends to mimic a maternal
relationship rather than a mutual romantic relationship, which makes the
experience all the more unique.
Gender
is also a factor: AIT affects female clients more than male clients,
and appears to occur more frequently between male therapists and female
clients, although we at CfBS know of instances where the client and
therapist are both female. When the client is male, the therapist
involved is usually also male. We have occasionally come across AIT with
male clients and female therapists, but the therapist has always been
much older than the client. We have never come across AIT between an
older male client and a younger female therapist, although this
gender/age combination is perhaps also uncommon.
What helps to reduce the risk of AIT?
Risk
of harm could be reduced if therapists routinely assessed their
clients’ vulnerability to AIT, especially the more regressive forms of
AIT, at the beginning of the therapy. We have noticed that the following
three traits are strongly associated with regressive AITs:
the client has a history of dependent/idealised relationships, especially with health professionals
they are primarily seeking care, not insight into their problems
they hold unrealistic views about what therapy can provide.
We
have worked successfully with clients who have a history of
dependent/idealised relationships but do not have the other two traits.
Where all three traits are present, our experience is that the client
will be so strongly predisposed to regressive AIT that serious
consideration should be given as to the appropriateness of one-to-one
therapy. Consideration should also be given to the gender of the
therapist. While the literature suggests that intense transferences are
not gender specific, we have found that clients are often predisposed to
develop AIT with therapists of a specific gender, and that they want to
see a therapist of that gender.
The
risk of AIT can also be reduced by responding appropriately when
clients bring up transference concerns, as AIT is much more likely to
occur if the first indications are ignored. Most clients tell us that
they attempted to discuss their concerns at an early stage in the
therapy, but did not get a helpful response. Instead of being alerted to
the potential for harm, therapists often act in ways that escalate the
problem. This includes disclosing their own feelings of attraction for
the client, assuring the client that the feelings will pass and
asserting that the feelings really are a reflection of the therapist’s
qualities.
Crucially,
we have observed that therapists whose clients develop AIT are unlikely
to discuss transference, and are dismissive or hostile when clients
suggest it. Clients also describe therapists becoming irritated,
defensive and rejecting in response to discussion about the adverse
effects on the client’s life (see the box for how the risk of AIT may be
reduced).
Box 2: How to reduce the risk of AIT
Inform clients about the phenomenon at the beginning of the therapy.
Carry out regular reviews in which the potential for AIT is monitored.
Maintain consistent professional boundaries and refrain from personal disclosures that could encourage idealisation.
Refrain from making the client feel special.
Be clear that the relationship can only ever be professional.
If the potential for AIT becomes apparent, discuss it with the client in order to work out the best way of tackling it.
Take it to supervision and seek external consultation if it persists.
Take responsibility for any actions that contributed to the idealisation.
Refrain
from acting defensively by blame, rejection and sudden rigid
boundaries, or terminating the therapy without the agreed notice period.
Informed consent and AIT
Clients
who develop AIT tell us they wish they had been warned about the
possibility before the therapy began. They often point out that a drug
with the same adverse potential would only be prescribed with informed
consent. Most feel that, if they had been informed of the risk
beforehand, the experience would have been less confusing and traumatic.
This is discussed in some published client accounts of adverse
experiences of therapy. For example, Simpson12 writes that she would
have considered descriptions of idealising transference to be ‘far
fetched’ if anyone had tried to warn her about it, but states: ‘If I had
been warned, and decided to ignore the warning, I think I would have
felt less cheated.’ Other therapy ex-clients, writing on the internet,
describe feeling ‘furious’ and ‘tricked’ because they were not warned
about this (www.mentalhelp.net). Many describe how they tried to
research the phenomenon but felt frustrated by the absence of
information.
Informed
consent has not been embraced by the counselling and psychotherapy
profession.16 This is perhaps because there has been almost no
discussion of the risk of harm from transference. There may also be a
fear that clients will be discouraged from engaging in psychotherapy or
made anxious by raising the issue. These are, however, all factors that
other healthcare workers negotiate successfully. For example, it would
be unethical for a surgeon to recommend an operation without first
discussing the potential adverse effects.
In
our experience, AIT interferes with clients’ capacity for rational
thought, making them vulnerable to both dependency and exploitation. As
such, AIT is a potentially serious side effect of psychotherapy. The
absence of discussion in the professional literature about this type of
harm is concerning because there is much a therapist can do to
discourage an idealising transference from becoming adverse. If
therapists don’t know about it, however, there is a clear risk that they
may unwittingly encourage it. What we hear from people who have
developed AIT is that therapists should have a greater awareness of what
might encourage it, and that clients should be informed about the risk
before they embark on psychotherapy.
With thanks to the clients of the Clinic for Boundaries Studies who have given permission for their experience to be used.
Dawn
Devereux was Director of Public Support at the Clinic for Boundaries
Studies and is currently on sabbatical. She has a special interest in
helping to resolve problematic situations in therapy. Email
dawn.devereux@ntlworld.com
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