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Some Hazards of the Therapeutic Relationship



Cultic Studies Journal, 1986, Volume 3, Number 2, pages 234-242

Some Hazards of the Therapeutic Relationship

Jane W. Temerlin, M. S. W. 

Maurice K. Temerlin, Ph. D.

Abstract

A hazard of long-term psychotherapy is the possible erosion of the boundaries of the therapist-client relationship. Previous work has shown how charismatic psychotherapists can so manipulate the therapeutic relationship that they produce groups which function much like destructive religious cults. This paper describes the intrapsychic and interpersonal processes which lead to a destructive erosion of therapeutic boundaries as observed in psychotherapy cults. Techniques used by cult therapists are grouped in four categories: those which a) increase dependence, b) increase isolation, c) reduce critical thinking capacity, and d) discourage termination of therapy.

One hazard of long-term psychotherapy is the possible erosion of the boundaries of the therapist-client relationship, with the result that the parties become enmeshed in multiple relationships which, at best impede therapeutic progress and, at worst, are extremely destructive. In a previous paper (Temerlin and Temerlin, 1982), we described how five charismatic teachers of psychotherapy manipulated the therapeutic relationship to produce cults, which then functioned much like the destructive religious cults described by Appel (1983), Rudin & Rudin (1980), Singer (1979), West and Singer (1980). The cult-creating therapists in our study established multiple relationships with their clients. For example, they brought their clients into their lives as students, supervisers, employees, spouses, lovers, colleagues, debtors, or servants, while simultaneously treating them as patients. The therapy then became destructive to those patients (although many did not know it at the time), who gradually became more dependent, submissive, confused, depressed, and less autonomous in the conduct of their lives.

These observations were based in part on intensive clinical study of twenty-six former clients of the five cult-producing therapists. The clients themselves were therapists, some of whom had been in therapy for more than ten years. While the cases they illustrate are extreme, and our research has all of the classic limitations of clinical methods, we nonetheless think that it illustrates the dangers of psychotherapy when limits and boundaries are not maintained. In the study, we concentrated on how the five therapists created cults, the ways in which the groups recruited new members and maintained old ones, and the effects on the personalities of the clients. Now, we will discuss intrapsychic and interpersonal processes in both therapist and client which, when their relationship is not confined strictly to therapy, permit the erosion of the boundaries of therapy, and make psychotherapy hazardous.

We will present material from our study of five therapy cults. While the cases are certainly not typical of the field as a whole, we think that a study of therapeutic relationships which seemed to increase the clients' submissiveness and reduce their autonomy, critical thinking, and capacity to make decisions independent of the therapist, while failing to decrease depression and paranoia, may teach us something about how the therapeutic process can be corrupted.

In the following outline we have grouped the hazards under three headings: idealization, dependency, and failure to maintain professional boundaries. All of our subjects seem to have suffered damage as a consequence of idealization of the therapis4 increased dependency, or extra-therapeutic contact with their therapists. Finally, we discuss techniques used by these therapists.

Idealization of the Therapist

All of the people whom we interviewed idealized their therapists. While admiration, and sometimes even idealization, of a therapist may facilitate positive change by creating an expectation of positive outcomes, idealization can also make clients vulnerable to exploitation by their therapists. Ethical therapists remain alert to this possibility and attempt to understand the client's idealization of the therapist as a projection or transference.

Cultic therapists, however, did not question the idealization, did not interpret it as a transference, but responded as though it was a deserved and accurate perception of themselves. Some therapists' statements in this regard include:

You are right; I am a genius, but it’s no problem for me. I have accepted that characteristic in myself.

I'm the best therapist in the world ... Mine is the best training program in the world.

I am my own consultant. I know of no other therapist who could adequately consult with me about my therapy.

The therapy I've developed has none of the defects of other therapies. [This was usually accompanied by emphatic denigration of other therapies and therapists.]

I know what you need better than you do. Your wish to terminate therapy is just blind resistance.

These therapists thus encouraged distorted perceptions of themselves. As a result clients developed unrealistic expectations of magical solutions, which in turn created the potential for despair, hopelessness, and depression. For example, once the therapist was idealized, clients blamed themselves for a lack of progress and change. The therapist encouraged this self-blame and often cited it as proof of the need for further therapy. Idealization seen as an accurate perception of the therapist also may prevent the client from accurately evaluating a therapist who is incompetent psychopathic, hostile, or exploiting.

Idealization that is not examined and understood also has hazards for the therapist. For example, the therapist may come to feel omnipotent or become megalomaniacal. He may use the client to repair his own self-esteem. Idealization may also hamper the therapist's ability to work through his own narcissistic problems, or reduce his capacity for testing reality. Indeed, idealization by the client may lead to despair and depression as the therapist senses the discrepancy between his own evaluation of himself and that of his clients. Idealization may thus lead to the therapist's dependence on the client's adoration for the maintenance of the therapist's public image or private self esteem.

Dependence on the Therapist

Many of the people we interviewed had stayed with their therapists for ten years or more; sometimes much longer. Such individuals obviously had problems with separation-individuation, and they reported being afraid to terminate, to be alone, to separate. Their self-confidence had been eroded by the "therapeutic relationship" which had isolated them from those outside the cult. They reported paranoid attitudes about the "outside world" and found it difficult to trust anyone who was not a member of their therapeutic group. Long-term involvement with an authoritarian therapist seems also to have increased clients' dependency in that they were less able to make personal decisions or new friends unless the therapist approved. As time passed they became increasingly submissive, anxious, and fearful. In some cases, the fear was realistic; they were aware that some clients who had terminated were sued or physically attacked. It is important to note that dependency was not always reflected in the clients' external lives; they were often quite successful in business or the professions. The dependency lay in their personal lives and intimate relationships.

Hazards of the Failure to Maintain Personal Boundaries

In all the therapy cults we studied, the therapist involved the client in his personal life; clients became their therapists' friends, students, lovers, colleagues, employees, drinking companions, research assistants, etc. This created great hazards for both. The clients became confused as the professional relationship eroded into a social one. They were unable to distinguish a transference from a realistic response to the therapist. They became more infantile and dependent. If sexual contact took place, severe depression and feelings of abandonment followed. Submissiveness to the therapist increased as acquiescence in the therapist's wishes became common. Consequently, patients exercised less and less control over their lives.

Therapists in such relationships often become grandiose, surrounded as they are by adoring patients. They may lose the capacity for realistic self-appraisal, and they may have marital problems because spouses resent involvement with patients in domestic situations. Such therapists may also face legal problems, censure from other professionals, and eventually experience fear and paranoia over other professionals' disapproval.

Techniques Used by Cult-Creating Therapists

This sampling of techniques is not inclusive, nor does inclusion  -mean that we think the techniques are always destructive. But each was described to us by one or more subjects as having been destructive to them in the context of the cult. We have grouped the techniques according to the function we think they served in the cult.

1.        Techniques which increase dependence

  1. Encouraging confession, in individual or group therapy, and then relieving the anxiety and guilt surrounding the confession through reassurance, forgiveness, criticism, or punishment rather than by supporting the clients' attempts to reformulate their own self-evaluation in a more benevolent fashion.
  1. Increasing dependency by relieving the client's anxiety or guilt with reassurance, advice, a "gimmick" or a technique which depended upon the placebo effect or suggestion, rather than exploring the anxiety or guilt and supporting the clients own attempts to reassure or forgive themselves.

c. Sexual involvement with the client, which created guilt, confusion, increased self-blame, and the feeling in the client that he Or she must protect the therapist from public or professional exposure, thus echoing the dynamic of incest and child abuse. (In cases where the client had actually experienced incest and child abuse, sexual contact with the therapist intensified the effects of the early abuse and increased the client's helplessness by encouraging dissociation and, in two cases, psychosis.)

d. Vacillating unpredictably between the expression of loving, gentle, and accepting attitudes toward the client to hostile, critical, and threatening ones. (Several clients reported being frozen by this technique, unable to move closer to the therapist because they feared him, and unable to leave because they felt he loved them.)

e.  Encouraging the client, as part of the therapy, to refrain from making any personal decisions without first discussing them with the therapist. This technique included criticizing any independent decision-making by clients, and praising them for complying with the therapist's recommendations.

f.        Taking advantage of non-therapeutic sources of influence over the patient, e.g., by treating employees, students, colleagues, or friends, and by becoming involved in financial transactions other than fee-for-service arrangements, such as lending money to clients.

II. Techniques which increase isolation (and thus dependence, Indirectly)

a. Treating clients in therapy communes, at extended retreats, on long trips, and the like, away from their usual network of relationships.

b.  Prescribing long periods of solitary meditation.

c.  Interpreting the client's problems as caused by family, friends, spouses, and/or children, and recommending that these people be avoided or rejected in the name of therapy.

d. Employing fear-inducing fantasies: for example, by asking the client to imagine how others would feet about him or her if they knew the client as well as the therapist did. Would others feel hostile, contemptuous, or have other negative attitudes toward the client?

e. Recommending that the client associate only with the therapist's other clients ("for mutual support during the difficult times of therapy," as one therapist put it), and selecting friends, dates, and spouses for clients.

f. Conducting group therapy among clients who also live and/or work together, so that "group think" obscures individual critical thinking and group processes can be used to create a "we" versus "them" attitude, as well as mutual admiration and support for the therapist.

g.        Denigrating all other forms of therapy and therapists, thereby essentially communicating the message: "you're better off with me," or, "If I can't help you, nobody else can."

III. Techniques which reduce critical thinking capacity

a. Denigrating intellectual activity as a method for solving personal problems by encouraging the client to "stop being intellectual" or by defining critical thinking as "being negative." The therapist using this technique fails to distinguish between the clients use of the intellect to clarify and understand internal processes and using the intellect to stop the experience of these processes.

b. Encouraging the client to use therapy jargon.

c. Encouraging faith in the therapy and the therapist rather than supporting the client's critical thinking and personal hypothesis-testing through experience.

d. Using vague, undefined terms and non-testable concepts in framing interpretations of phenomena.

e. Talking to the client in complicated sentences with internal contradictions, and then interpreting the client's attempts at clarification through questioning as resistance, or as a character defect. One therapist, for example, typically responded to a client's questions with: "If I have to explain it, you couldn't understand it; you are just not ready to understand anything you have to ask me about."

f. Responding to the client's questions about him or herself by recommending chanting, meditation, exercises, or relaxation techniques while simultaneously ignoring the content of the question.

g. Recommending that the client avoid confusion by avoiding the  seminars, and workshops of other therapists.

h.        Redefining the client's problem in terms that cannot be verified personally through observation and experience. For example, one therapist refused see a couple together concerning marital problems because his diagnosis showed that each was "really" suffering from a trauma which occurred during the first year of life. What they considered to be marital problems were simply superficial symptoms. He then saw them separately for years of fruitless free association to uncover the pre-verbal trauma, without ever resolving the marital problems. They stayed with the therapist for a long time because each thought that his opinion was more valuable than their own.

        

IV.  Techniques which seem to discourage termination of therapy

  1. Gradually reversing roles by telling the client more and more about the therapist's own personal life and problems. (While clients were at first flattered and sometimes moved by such confidences, they began to modify their expectations of therapy and gradually started to protect and defend the therapist, putting his needs above their own.)
  1. Interpreting a wish to terminate therapy either as disloyalty to the therapist, or resistance to therapy itself.
  1. Telling a client who wishes to terminate that he or she has made man positive changes but is not conscious of them at this time in therapy, and that they will appear with more therapy, later.
  1. Telling a dissatisfied client who tries to terminate that the gains he or she has made are spurious, and that they will disappear if the client actually leaves.
  1. Defining the goals of therapy or reframing the client's original goals, it vague, mystical, or non-referential terms, and then mentioning specific goals that have not yet been achieved when the client proposes termination.
  1. Telling the client who starts to terminate with feelings of dissatisfaction that, as one therapist put it "I'm as good a therapist as there is; if you can't succeed with me, you'd be a disaster with anyone else."

Conclusions

To some extent, idealization of, and dependence upon, a psychotherapist may be inherent in seeking help. However, it is the erosion of the boundaries and limits of the relationship between therapist and client which makes exploitation of the idealization and dependency possible and harmful. When therapists limit their relationship with the client strictly to psychotherapy, much harm is avoided, and the idealization and dependency can then be worked through and resolved rather than lived out in the relationship. While most therapists are ethical, and many studies show that psychotherapy generally is helpful (Bergin & Lambert, 1978; Luborsky, et al., 1975, Meltzoff & Kornreich, 1970; Parloff et al., 1978; Smith & Glass, 1977), the combination of the techniques we described and the blurring of therapeutic boundaries by charismatic therapists can result in harm to vulnerable clients and to the therapists themselves.

*****

This article was first presented as a paper to the Annual Conference and Training Institute, American Academy of Psychotherapists, Chicago, IL, October 17-21, 1984.

References

Appel, W. (1983). Cults in America: Programmed for paradise. New York: Holt, Rinehart & Winston.

Bergin, A. E. & Lambert, M. J. (1978). The evaluation of therapeutic outcomes. In S. L. Garfield and A. E. Bergin (Eds.), Handbook of psychotherapy and behavior change (2nd ed.). New York: Wiley.

Luborsky, L. Singer, B. & Luborsky, L. (1975). Comparative studies of psychotherapies. Archives of General Psychiatry, 32, 995-1008.

Meltzoff, J. & Kornreich, M. (1970). Research in psychotherapy. New York: Atherton Press.

Partoff, M. B., Wolfe, B. E., Hadley, S. W. & Waskow, 1. E. (1978). Assessment of psychosocial treatment of mental disorders: Current Status and Prospects. Report to the Institute of Medicine, National Academy of Sciences (NTIS no. PB-287 640/7WS).

Rudin, A. J. & Rudin, M. R. (1980). Prison or paradise? The new religious cults. Philadelphia: Fortress.

Singer, M. T. (1979). Coming out of the cults. Psychology Today, January, 72- 82.

Smith, M. L. & Glass, G. V. (1977). Meta-analysis of psychotherapy outcome studies. American Psychologist, 32.

Temerlin, M. K. & Temerlin, J. W. Psychotherapy cults: An iatrogenic perversion. Psychotherapy: Theory, Research, and Practice, 19, 1982.

West, L. J. & Singer, M. T. (1980). Cults, quacks, and nonprofessional psychotherapies.  In H. I Kaplan, A.M. Freeman, and B. Sadock (Eds.), Comprehensive textbook of psychiatry III.  Baltimore: Williams and Wilkins.

Jane W. Temerlin, M.S.W., and Maurice K. Temerlin, Ph.D., are therapists in private practice in Oklahoma City.