Book Review by Lawrence E. Hedges, Robert Hilton, Review by Virginia Wink Hilton, and O. Brandt, Mary D. Laney Caudill, Jr.
Therapists at Risk: Perils of the Intimacy of the Therapeutic Relationship
Northvale, NJ: Jason Aronson, 1997.
328 pp. ISBN 1-56821-827-3. $40.00
Lawrence E. Hedges is the founding director and supervising and training psychoanalyst of the Newport Psychoanalytic Institute (California). Hedges also serves as director of the Listening Perspectives Study Center; maintains an independent practice specializing in training psychotherapists in Orange, California; and holds faculty appointments at the California Graduate Institute and the University of California, Irvine, Medical School. Hedges is the author of numerous papers and texts, including Listening Perspectives in Psychotherapy, Interpreting the Countertransference, In Search of the Lost Mother of Infancy, and Working the Organizing Experience. ■ Robert Hilton has been in independent practice for 31 years in Orange County, California, and has taught at the University of California (Irvine and San Diego [La Jolla]) and at the United States International University (La Jolla, California). In 1972 Hilton co-founded the Southern California Institute for Bioenergetic Analysis, where he continues as a senior trainer. ■ Virginia Wink Hilton is executive director of the International Institute for Bioenergetic Analysis and formerly served as director of training for the Southern California Institute for Bioenergetic Analysis. Hilton has been in independent practice for 20 years and has taught and trained psychotherapists in the United States and numerous European countries. Hilton’s research interests include ‘sexual issues in the therapeutic process, professional ethics, and the relationship between sociocultural issues and personal process. ■ O. Brandt Caudill, Jr., is an attorney specializing in the defense of psychotherapists in civil litigation, before ethics committees and licensing boards. Caudill is coauthor, with K. S. Pope, of Law and Mental Health Professionals. ■ Mary D. Laney, assistant professor at the University of Medicine and Dentistry of New Jersey (Newark), also maintains an independent practice in clinical and forensic psychology in Metuchoen, New Jersey. Laney is a candidate of the Institute for Child, Adolescent, and Family Studies (New York) and author of “Perspectives and Interventions: Psychoanalysis and Psychoanalytic Psychotherapy, Family Therapy, and Community Psychology” in M. Lewis and S. Miller (Eds.) Handbook of Developmental Psychopathology.
This compilation of chapters offers contributions from bioenergetic psychotherapists, a psychoanalyst, and an attorney specializing in the defense of psychotherapists in civil litigation. Many of the chapters originally were written for publication elsewhere, or adapted form works previously published. Though they appear together, the chapters do not form a cohesive whole. Rather, the book may be characterized by two dominant themes: (a) the application of psychoanalytic theory and concepts, notably transference and countertransference, to the analysis of heightened risk exposure currently incurred by psychotherapists and (b) legal and ethical considerations regarding current issues and risks within the domain of psychotherapy. Each of these themes could have been developed independently, in separate books. As they appear, with little exception, there is a lack of integration and synthesis.
Given the litigious nature of our current social climate, all practicing psychotherapists are at increased risk. However, the psychoanalytic concepts utilized throughout most of the book are, at times, at variance with other forms of psychotherapy. As noted by Williams (1997), the application of analytic concepts is meaningless and offensive to numerous practitioners. Therapists who practice humanistic, behavioral, or other eclectic forms of psychotherapy have cogent reasons to counter even the most basic of classical psychoanalytic tenets. For example, behavioral therapists may frequently self-disclose through modeling or self-report about their own means of change. Within a behavioral frame, such disclosures are not conceptualized in terms of transference. Moreover, different standards of care may exist for different forms of therapy, as well as within the field of psychoanalysis. The failure to acknowledge such differences and the failure to convey a psychoanalytic perspective in the title are shortcomings of the book.
Although boundary violations may be used to subsume the majority of complaints against therapists, in this book, the issue of boundaiy was addressed more indirectly, with brief, direct discussion of the topic. The discussion of boundary issues in relation to early mother-child interaction and defense, though theoretically sound, does not address the pervasive subtle and overt breaches of boundaiy through a wide range of clinical, ethical, and legal considerations (see Goisman & Gutheil, 1992; Gutheil & Gabbard, 1998; Simon, 1992). Nonetheless, the author’s means of managing erotic transferences and inappropriate self-disclosures, as well as framing of the therapist’s disclosure in ways that retain boundaries, are helpful. The inclusion of risk management ideas and strategies designed to reduce the perception of boundary violations or excessive intimacy would have been a valuable addition.
The inclusion of a chapter on touching in psychotherapy addresses an important and avoided topic. Again, the treatment of the topic is somewhat one-sided, There is no integration with chapters related to legal considerations, nor is there any acknowledgement of this dimension a$ it relates to behavioral, Gestalt, or other forms of psychotherapy. Nonetheless, the chapter draws emphasis to the context in which touch occurs and the importance of this dimension to a decision of whether or not to touch patients. Through his own disclosure, the author exemplifies the value of a clear theoretical stance which is supportive and consonant with the decision to touch a patient. The author’s caution that a therapist needs to be aware of the present transference relationship when he or she makes the choice to touch a patient, may not always be possible. The intent of the therapist may be at odds with the experience of the individual being touched. Particularly in multiplicity of personality, it is difficult, if not impossible, to know the personality constellation of the person being touched. Nonetheless, the author’s comments regarding touch and regressive behavior and the therapist’s personal needs and obligations to accept responsibility for their touch are direct, clear, and unwavering.
Despite the seemingly dangerous title of the chapter “In Praise of the Dual Relationship,” the thoughtful and applicable suggestions offered at the conclusion of the chapter are extremely valuable and could function as safeguards. Though suggestions are cast in terms of a psychoanalytic orientation, many of them, especially those regarding the use of expert consultants, could be extended to include practitioners of other therapeutic perspectives. The idea of providing regulatory boards and ethics committees with guidance from consultants in the orientation practiced by the therapist charged with a violation is quite reasonable. The most important point of this chapter, however, is the author’s advocacy for discovery and due process for any therapist charged with a violation or complaint. The implementation of such practices would, indeed, afford more precise knowledge of the scope and details of the accusation. The implementation of these suggestions would greatly benefit therapists facing accusation and litigation. Similarly, the use of arbitration panels sophisticate in the theoretical frame in which the questioned activity occurred appears extremely sound. More of this interweaving of therapeutic and legal considerations throughout the book would have been welcomed.
The chapters by Caudill, an attorney specializing in defending psychotherapists before ethics committees and licensing boards, are extremely valuable and timely.
His focus on trends in litigation and accusations against psychotherapists is pertinent and clearly documented. These chapters provide concrete, objective aspects of the current risks and accusations targeting therapists. Moreover, they are cogent, enjoyable, and filled with practical applications that may be implemented as safeguards and prophylactic efforts to reduce risks. Devoid of passion, Caudill uses a matter-of-fact style and draws on his expertise to place the current trend in therapist liability and litigation in a historical context. After tracing that history from the Tarasoff decision in 1976 (Tarasoff v. Regents of California, 1976), Caudill moves to the discussion of standards of care In an unbiased, impartial manner. Emphasis to the sensitive issue of repressed memory, with an important focus on the means through which therapists arrive at their beliefs regarding this issue, are central to his chapter. The inclusion of practical strategies such as record keeping, recording of relevant literature, consultations, that lead to one’s decision are, again, invaluable.
Similarly, Caudill’s emphasis on the development of a superordinate business concept for the various relationships that therapists must enter are strategic and wise. His comments regarding those relationships with patients, employees, trainees and supervisees are sagacious and should be required reading for all practicing psychotherapists. The only notable absence from these chapters is an omission of the discussion of the pervasive use of boundaiy violations by litigants and particularly plaintiff attorneys seeking to access malpractice insurance not accessible through claims of sexual misconduct. Attention to the ethical and legal considerations of this phenomena as well as means through which therapists may protect themselves would have been very helpful.
Despite its limitations, this book clearly offers many interesting and helpful ideas. The authors draw on their experiences, expertise, insights, and opinions to confront a very difficult and time-sensitive subject. The outcome is both generous and valuable. Finally, though perhaps misplaced, many of the expressed analytic opinions and the analysis of the therapeutic relationship, per se, would be of great interest to psychoanalytic, psychodynamic practitioners.
Goisman, R. M., & Gutheil, T. G. (1992). Risk management in the practice of behavior therapy: Boundaries and behavior. American Journal of Psychotherapy, 46, 533-543.
Gutheil, T. G., & Gabbard, G. O. (1998). Misuses and misunderstanding of boundary theory in clinical and regulatory settings. American Journal of Psychiatry, 155, 409- 414.
Simon, R. I. (1992). TYeatment boundaiy violations: Clinical, ethical, and legal considerations. Bulletin of the American Academy of Psychiatry and Law, 20, 269- 287.
Tarasoff v. Regents of University of California, 131 California Reporter 14, 551 p. 2d 334 (1976).
Williams, M. H. (1997). Boundary violations: Do some contended standards of care fail to encompass commonplace procedures of humanistic, behavioral, and eclectic psychotherapies? Psychotherapy, 43, 238- 249.