Sherry Mehl, Executive Director
Board of Behavioral Sciences
400 R. St. Suite 3150
Sacramento, CA 92814
Re: Increasing awareness of how the “Organizing” or “Psychotic” transference operates in the accusation and investigation processes.
Dear Ms. Mehl,
As we discussed on the telephone, I am writing concerning a matter that has weighed heavily on me for some time. It is my belief that consumers as well as psychotherapists are currently being misled and damaged by a critical gap in knowledge about the nature and operation of transferences caused by infantile trauma.
My primary professional activity for twenty-five years has been coaching therapists through their most difficult cases—in individual tutorials as well as in case conference groups. I have consulted on more than fifty cases involved in some type of complaint process in five states and have served as an expert witness on a series of cases brought before licensing boards. I have tried (not always successfully) to limit my work to cases in which I believed the therapists were doing an average, expectable job with their clients. And in which the therapy process had fallen prey to primitive transferences giving rise to distorted, faulty, and/or false accusations against the therapist.
In the course of my work I have witnessed many serious breaches in law and ethics on the part of therapists who were abusing and taking advantage of their clients. I whole-heatedly support our investigation processes and believe that prompt and effective disciplinary measures should be taken against all who violate our legal and ethical standards.
It is clear to me that licensing boards and ethics committees have a very difficult task. It is also clear that the current knowledge base and operating policies allow most circumstances to be handled effectively and appropriately. For this I congratulate those who devote their time and energy to insuring that psychotherapy remains a viable, effective, and safe professional enterprise in our society. However, a glaring gap in one particular area of knowledge and expertise needs to be addressed.
The Knowledge Gap
There exists a widespread lack of awareness regarding a psychological structure referred to as “the organizing transference.” This transference structure is formed in early childhood in response to infantile trauma during the organizing period of development. In our literature this phenomenon has been assigned the label “transference psychosis” because it emerges as a deep transference structure in long-term, intensive psychotherapy. And called “psychotictransference” because, when the client transfers this early emotional scar into the psychotherapy situation and onto the person of the therapist, the client’s capacities for ordinary perception and reality testing are eclipsed. Under these conditions the person experienced in the past as perpetrator of the infantile trauma is confused with the object of the transference in the present—the therapist who has worked hard to elicit the transference. The current acute distress at having to re-experience in therapy the deep psycho-physical trauma is “blamed” on the therapist—for, after all, it is he or she that has been active in bringing the long forgotten past agony into the experiential present.
Since many otherwise sane people have a history of some kind of infantile trauma and are occasionally subject to such deep transference-memory regressions, I do not like the term “psychotic” which implies some sort of wild crazy madness. The terms “organizing experience,” “organizing memory structure,” or “organizing transference” better describe the origin of the experience that is being revived for therapeutic work. That is, a fetus or an infant while organizing psychological channels to the environment for nurturing, soothing, and tension relief is met with some form of invasive trauma. A traumatized infant typically reacts with agitation and, in extreme cases, terror. Intense fear in infancy is painful and accompanied by physical constrictions, diffuse physiological stress, and severe emotional withdrawal. It is the revival and working through of these regressive psycho-physical experiences in the present psychotherapeutic transference that permits eventual recovery and growth.
Most licensed therapists may never encounter the organizing transference because they are doing short term work, cognitive or behavioral interventions, family or couple counseling, industrial or forensic consulting, or support groups of various types. But any therapist who has been seeing individual clients for very long inevitably attracts some people who need extended care. Psychotherapeutic relationships which last for more than a few months raise the likelihood that in time a significant emotional relationship will develop. It is the deepening of the therapeutic relationship that makes possible the perception and analysis of the well-known narcissistic and borderline transferences as well as the little understood organizing transference.
Many competent therapists doing long-term work have, in the course of their professional development, made it a point to seek out additional supervision and continuing education as needed in order to successfully bring out the merger fantasies, split affects, dissociations, and projective identifications involved in deep work. And ethics committees and licensing boards are becoming accustomed to dealing effectively with complaints arising from narcissistic and borderline transference structures. However, in areas of deeper regression to the organizing transference understanding remains limited.
Tansference Memories of Infantile Trauma
There exists a significant and growing group of clients whose therapeutic needs press them to explore deeper or “more primitive” transference structures which contain the memories of infantile trauma. Infantile trauma can result from the many kinds of overt or covert molest, abuse, or neglect that we already know about. But infantile trauma—either experienced in utero or in the earliest months of life—can also result from such things as toxemia in pregnancy, fetal exposure to alcohol and drugs, premature birth, birth trauma, birth defects, separation from the biological mother, adoptions, incubators, foster placements, medical procedures, parental or familial distress, holocaust conditions, maternal depression, and a myriad of other highly stressful conditions. Infantile trauma can be focal and acute, or it can be diffuse and cumulative in its effect on the developing child.
The Terror of Human Connections
What is it that characterizes this group of clients who have experienced severe infantile trauma? Terror—deep seated, non-conscious terror that if they reach out for interpersonal emotional connection they will be re-traumatized. The transference expectation insures that they will experience terrifying, body shaking, soul wrenching trauma in response to close emotional contact. The very nature of this transference alerts these people to the threat that, if anyone approaches them in emotionally significant ways they will once again feel injured. Every cell in their bodies yells out, “Danger! Danger!,” whenever they dare to experience the possibility of human connections that have the power to heal them.
I frequently travel and lecture, conduct classes and seminars, and I meet privately every day with groups of therapists teaching them about the effects of infantile trauma. I attempt to show them the ways that the organizing transference asserts itself as a terror of empathic connections. The knowledge expansion in the field of psychotherapy over the past three decades has taught most therapists the empathic skills involved in “connecting,” “holding,” and “containing” techniques appropriate for narcissistic and borderline transferences.
But therapists generally do not know, nor is it intuitively obvious, that many clients who were traumatized before ordinary forms of communication and memory developed, have no choice but to experience the connecting overtures of the therapist as seductive, frightening, and painful. Nor is it intuitively obvious that ordinary empathic connections—which most therapists have been taught to value—paradoxically function in the organizing transference as intrusive re-traumatizations that the client must avoid as much as possible, fend off, and eventually rage about and/or flee from in terror.
Is it any wonder that so many of these clients cry out in pain and seek public redress for their experienced injuries? Therapy promised them healing. The therapist promoted relationship. And relationship led to terrifying and painful regressive transference experiences which they could not bear. Reality testing weakened. Then, in the revival of the confused and traumatized state of infancy, the therapist was experienced as the perpetrator.
I coach therapists daily as they struggle with their clients through this most treacherous of passages—through deep body-mind terror on the way toward learning how to make and to sustain human connections that have the power to cure. Much of our work is devoted to learning how the specific client characteristically desires and approaches the therapist for the human warmth and connection that they have been deprived of for so long. We study week after week, month after month, exactly how each client begins to experience the connection to the therapist. Then we wait and watch exactly how the client instinctively falls into deep fear, physical symptoms, disorientation, and contact avoidance. Studying in each client the operation of the pre-defense fear mechanisms common to all mammals—freeze, fight, or flee—aids us in the discovery and working through process toward safe interpersonal connections and emotional interactions which allow growth and healing.
There is no way we know at present to determine in advance the exact nature of the trauma experienced at the base of a person’s psycho-physiological being. Nor is there any known way to predict exactly how that trauma will reassert itself in the approach-avoidance matrix of the therapeutic situation as the transference/countertransference struggle unfolds.
It is clear that the terror of interpersonal connection these people experience is distinctly different from the fear of abandonment that people working on narcissistic and borderline transferences experience. Also clear is the agony of the accusatory cry revived from the traumatized infant self, “you hurt me when you came near me—when you touched me!” Or, in the reverse, is the fighting clamor to the effect that the therapist did not “give” or “do” enough. A harshly accusatory or incessant cry and struggle for “more,” of course, can serve to alienate the affections of the therapist so that deep emotional connections do fail—thus replicating the infantile trauma afresh. The struggle to get the therapist to be more attentive, or to do more, often purposefully functions to disturb or rupture the therapist-client empathy ties—the exact thing that produced the original trauma.
At the moment of confused, regressive, psychotic transference re-experiencing, the perception and reality testing of the client are sufficiently eclipsed so that the traumatic psycho-physical memory resurfaces in the present in a form that contradicts reality. That is, it is caring, reaching out, and the desire for compassionate healing connections that the therapist is offering. This offering elicits the impulse to reach out to find human connection. But then, because of the nature of the organizing transference, the emotional connection will be experienced as terrifying and painful. At such moments clients can actually perceive and believe that an abusive violation has occurred when in reality there was no such violation. Rather, early trauma was re-awakened and distortedly attached to what the therapist did or did not do.
The transferred infantile experience of sensual connection being traumatically intruded upon is thus, “you were loving me, encouraging me to open up to you, insisting that I trust you, and then you hurt me.” The “then you hurt me” takes endless forms as the historical specifics of the client’s infantile trauma emerge. But the archaic, sensual body memory of trauma is now emerging in an adult with a fully sexually-charged body. And the transferred experience is often felt to be a sexual or quasi-sexual intrusion.
Staying with such persistent and traumatic structures takes stamina on the part of both therapist and client. At any point in the process, one or the other could, for any of a variety of reasons, falter in intent or determination. Or an outside unforeseen event could interrupt the working through process with disastrous consequences. This is often the point at which complaints are filed. There is a significant knowledge gap about the nature of this kind of transference remembering. And there is a knowledge gap regarding how therapeutic technique for this kind of work necessarily differs in major ways from work with narcissistic and borderline transferences.
The Damage Created by the Knowledge Gap
Consumers who approach psychotherapy with the hope of having their deep trauma wounds healed are being misled when many therapists haven’t the slightest idea how even to identify the organizing or psychotic elements in deep transference, much less how to work with them. For example, many “recovered memories” attributed to later events can undoubtedly be traced to transference effects of infantile trauma that has been misunderstood by therapists. This is the subject of my text Remembering, Repeating and Working Through Childhood Trauma, (Aronson, 1994). Licensing boards have an obligation to consumers to address this knowledge gap in an aggressive and creative way before more damage is done.
When training therapists I often say, “It’s not just your own neck that’s at stake if you naively conduct yourself in such a way that allows you to be the target of a transference accusation; but the progress and wellbeing of the client as well. No client was ever cured of infantile trauma in an investigation process or in a courtroom. If you don’t know what you’re doing you will bring disaster on yourself. And you will have failed in the trust relationship and the cure you had worked so hard to achieve.”
A Brief History
The organizing (or psychotic) transference, was first extensively studied by Sigmund Freud in his famed Schreber Case of 1911. Schreber, a well-known civil magistrate in Vienna, had published his scandalous memoirs of several hospitalizations for a severe and continuing paranoid psychosis. Among his many confirmed false allegations were claims of repeated violent and sexual assaults in the hospital by his treating physician and caregivers which Freud successfully traced to transferred infantile trauma.
Freud had earlier shown how the same kind of deficit in reality appreciation in the 1882 treatment of Anna O. had led her to blame her therapist for her false pregnancy. In Freud’s 1895 “Project for a Scientific Psychology” he clarified the dynamics of how childhood molestation not only leaves a person vulnerable to later molestations but how later intimate contacts can be psychologically confused with infantile intrusive trauma.
I first summarized the basic literature on the organizing or psychotic transference in my 1983 book, Listening Perspectives in Psychotherapy. I have subsequently published (with Aronson of Northvale, New Jersey) six additional textbooks for psychotherapists with clinical contributions from more than 200 clinicians, addressing this subject. Most relevant to this topic are: Working the Organizing Experience (1994) and In Search of the Lost Mother of Infancy (1994). Dr. James Grotstein, a Beverly Hills psychoanalyst and an internationally recognized expert on psychotic transference wrote a review of the literature with an extensive bibliography as a forward to Working the Organizing Experience. The recently published Therapists at Risk (Aronson, 1997) co-authored with Robert Hilton, Virginia Wink Hilton, and attorney O. Brandt Caudill, Jr., further elaborates the dangers to consumers and therapists.
The Need for Expertise in Closing the Knowledge Gap
Enclosed please find a series of papers in which I have specifically addressed the knowledge gap. “In Praise of the Dual Relationship” looks at dual relationships somewhat differently than you may be used to. I take the position that the heart and soul of depth transference interpretation rests on a principle of duality in which the real relationship is revealed to be distinctly different from the fantasized transference/countertransference relationship. On the opposite end of the duality spectrum lies the exploitation and damage created by engagements such as sexual acting out. There are many actions of therapists that clearly violate clients’ boundaries in exploitative and damaging ways. Such violations should be disciplined firmly and appropriately.
But in the “gray area” of the duality spectrum between useful transference interpretation and destructive boundary violations lie many activities engaged in by therapists and clients aimed at (1) developing the real relationship and (2) elucidating the transference/countertransference relationship. The intent and effects of activities and events in the gray area of the duality spectrum in long-term therapy can easily be misunderstood by outside observers. I take the position that ethically responsible professional opinion regarding the organizing or psychotic transference, requires careful and studied thought. Responsible and ethical opinion can be rendered only by properly trained professionals who possess such expertise—which includes many years of personal experience in actually doing and supervising long-term, intensive therapy.
In my paper studying dual relationships I specify the psychodynamic issues at stake and what such consultative expertise might look like, using the California Research Psychoanalyst Law as an already existing codified model of expertise. I asked the question if we could name even one licensed therapist who currently renders opinions on a licensing board or who is routinely hired as an expert witness by a licensing board who possessed such expertise. I expressed my belief that a great many therapists are operating unethically in board-related activities by rendering professional opinions in areas outside of their training and expertise.
Further, I called for the establishment of agreed upon standards regarding what constitutes expertise in understanding the workings of organizing or psychotic transference. I suggested forming a pre-selected panel of such experts who could be called upon to provide education, advice, and experienced opinion to licensing boards and administrative law judges.
Following the newly instituted requirement that the decisions of the administrative law judge be held binding in cases in which the credibility of the accusing consumer is in question, I would now suggest that such expertise not only be available to support the work of the licensing boards, but also that it be a regular and mandated part of the administrative hearing in such cases.
Perhaps a task force comprised of members of the various boards and professions should be formed to study the situation, to seek out expertise, and to make recommendations. Infantile trauma is here to stay and consumers who seek out therapy for such deep wounds have a right to know that this branch of psychotherapy is being appropriately monitored by the professions and by state boards. Perhaps an in-service training or consciousness raising day sponsored by each state board and ethics committee might be a first step in the recognition of the problem.
The Goal is an Educational One
I realize that my opinions and conclusions as well as my recommendations are offered at a time before state boards and ethics committees have had an opportunity to assess the nature and seriousness of the problem I am pointing toward. I further recognize that many professionals practicing psychotherapy may not even be aware of this knowledge gap. This is because only a relatively small sector of the therapist and client populations have as yet been impacted by the problem.
I wish to make clear that as an educator, my primary concern is the dissemination of information and knowledge. As a trainer and as a consultant to psychotherapists I am concerned about a knowledge gap that is widely affecting therapists and consumers alike.
The Magnitude of the Problem
Let me close by expressing my opinion as to the magnitude of this problem. I think of an avalanche slowly accumulating weight over a long period of time until one sparrow quietly settles on a small twig—adding just the right weight to precipitate an enormous disaster. I believe the avalanche is in place and that it is precariously balanced at present.
First, we have a large and frightened community of psychotherapists whose consciousness about these matters is slowly rising. Many are slowly aiming their sights toward licensing boards which they believe to be the source of a serious danger that is not being addressed and which threatens them personally, their professional practices, and affects what clients they feel safe working with.
Secondly, we have a large, politically powerful and incensed population of “seriously mentally ill” consumers who, first because of unenlightened treatment approaches, then because of the managed care industry, and now because of frightened therapists blaming licensing boards feel they are being denied treatment. These people have organized nationally and locally to lobby for protective legislation and are increasingly targeting the licensing boards as the current cause of their not being able to obtain treatment because therapists are afraid of the serious liability involved in taking them on.
Thirdly, we have a formidable group of pre-licensed trainees, graduate school educators, and training clinic personnel who are in acute distress because of the sudden drastic diminishment of apprenticeship opportunities. Many supervisors, even senior clinicians who have been involved in supervision and training for years, are now loathe to involve themselves with pre-licensed training, or even to engage in case supervision of licensed therapists because of disturbing disciplinary actions of state boards which have held supervisors accountable for the inappropriate actions of people they are helping to train. Professionally responsible supervision and training is slowly grinding to a halt until more safety nets are in place for supervisors.
Finally, we live at present in a super-charged social atmosphere. Whether we choose to speak in terms of a “litigious society” or in terms of “an era of increased accountability,” legislators, judges and jurors, governors, and the public at large are all concerned about liability and about damage to innocent victims. Therapists are running scared because they have no reassurance that their deep transference work will be understood and respected if an accusatory situation arises.
The State Boards Must Be Accountable
It is my purpose in this letter to begin a calling to account of the state boards and the ethics committees of the various professions by pointing out the serious liability which currently exists because of a critical knowledge gap regarding the dynamics of organizing or psychotic transference. Liability through ignorance is sometimes excusable, but continued thoughtless practices after one has been informed of their damaging consequences are not excusable. Boards and Ethics Committees now stand informed. How they will choose to curtail the ongoing damage being done by the knowledge gap remains to be seen.
In my lectures around the country on the subject of false accusations and the existing flaws in administrative law, I am regularly met with angry shouts of protest. Some say, “Let’s sue the licensing boards!” And, as we know, suits against state boards regarding issues of discipline have begun and will likely increase. It seems only a matter of time before we have some class action suits involving millions of settlement dollars and widespread public embarrassment for licensing boards.
Others say, “We must take legislative action at once!” And as we know, this has already happened in Arizona where a grass roots movement of patients and therapists appealed to the legislature at “sunsetting time,” successfully blocking a scheduled reauthorization of the state board. Sunset time in California is just around the corner and a massive letter writing campaign to the legislature or to the governor could have disastrous consequences.
I am appealing to you and to all people involved in the investigation and disciplinary processes for psychotherapists to help in closing the knowledge gap. It is my impression that the ethics committees of the professions have long practiced obtaining outside expert opinion on these matters so their position seems less critical. The professional organizations at present are so beleaguered with issues brought about by managed care that they may be slow getting around to this set of issues. The welfare of many consumers is at stake as well as the board’s liability for enforcing fair and appropriate disciplinary standards on therapists.
The reality is that one disgruntled consumer or therapist could file an ethics complaint against all of the clinical members of all of the boards and all of the expert witnesses working for the boards who do not clearly possess the training and experience which would constitute expertise in this area. An ethics complaint against a number of licensed therapists would serve to create immediate pressure within the disciplines and within the boards to find ways of addressing the knowledge gap. But not without unfortunate consequences to the individuals involved.
In discussing my concerns with Muriel Golub, Ethics Chair for the California Psychological Association, it was her suggestion that this problem area be addressed in the most professional, ethical, and constructive manner possible. This would clearly involve educative efforts aimed both at individual licensees and at all participants who carry out the investigative and disciplinary processes. I completably agree.
It is my intent that this statement be the beginning of a dialogue to understand better the nature of infantile trauma and the way it affects the transference/countertransference relationship of long-term psychotherapy.
The goal is to initiate educational measures to help therapists deal more effectively with the organizing transference and to help investigative personnel at all levels discern its operation, seek appropriate consultation, and make the best decisions possible.
Thank you for your consideration of my concerns. I hope to be able to speak with you soon. In our brief telephone conversation several weeks ago you invited me to send you my papers on the subject. My offer to come to Sacramento for the purpose of discussing with you further the nature of the “organizing” or “psychotic” transference as it affects accusatory processes still stands.
Yours Very Truly,
Lawrence E. Hedges, Ph.D.
“In Praise of the Dual Relationship” (3 parts)
“False Accusations Against Therapists”
“Prevention of False Accusations Against Therapists”
Chairperson, The Ethics Committee
The American Psychological Association
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