Altruism and Boundary Violation

ABSTRACT

The desire to help others is a common motivation for becoming a therapist, and boundary crossings are an expectable part of psychotherapeutic work. However, progression to boundary violation is rare. The concept of an altruistic boundary violation is presented and illustrated with detailed clinical material drawn from the analysis of Mrs. A,¹ a generally ethical therapist, whose violation of the therapist/patient boundary with her patient, M, began as an altruistically motivated enactment and boundary crossing. In Mrs. A’s case, and arguably in all similar altruistic boundary violations, a specific fit existed between patient and therapist. The intense need to rescue this particular patient was fueled by Mrs. A’s history of early physical and abandonment trauma, which increased her vulnerability to overidentification with her traumatized patient. The stress of relocation to another city and closing her practice further magnified her susceptibility. The complex clinical, professional, ethical, and legal issues inherent in consulting on such a case are discussed. I describe my countertransference and my parallel enactment, an initial crossing of the boundary between the roles of supervisor and therapist.     

Restoring Dyadic Connection in the Face of Multiple Disruptions: Accounting for Vicissitudes in the Therapist’s Capacity for Reflective Functioning

This article describes the working method of our study group comprised of former Chestnut Lodge Hospital therapists and focusing on understanding therapeutic work with severely disturbed adolescents. Using process material from one therapy session, the therapist’s commentary on her feelings and reactions in the session, and the group’s discussion of the work, we explore factors disrupting the therapist’s moment-to-moment capacity to maintain a theory of her own and the patient’s minds. We then discuss what allows her to refind her theory of mind in the face of the patient’s aggressive nihilism and her own sense of loss. Salutary factors included the therapist’s empathy for the patient’s shared sense of grief, the patient’s offering the therapist cues to his inner state, and the dyad’s capacity to tolerate the therapist’s vulnerability in the patient’s presence.     

When the Tree Falls and No One Hears It: On Being Dropped and Learning to Hold

This case study focuses on a student therapist’s reflections upon a premature termination that occurred in her work with an adolescent male patient. The therapeutic process is traced back to the beginning of treatment, and the article delineates the extent in which the patient’s early interpersonal experiences influenced the development of the therapeutic alliance. The author addresses several themes that evolved throughout the treatment, including the patient’s experience of unpredictability and instability and his inconsistent understanding of time, and the ways in which these experiences ultimately influenced the treatment’s ending. The article describes the therapist’s development as a clinician over the course of the treatment, focusing on the various experiences that helped her consolidate a dynamic understanding of the holding environment.     

Conflicting interests and the creation of a “third space”; reply to commentary

This paper addresses how to be an available and responsive therapist to a controlling and narcissistically vulnerable young girl. It presents an overview of the treatment relationship and specific vignettes from sessions. The paper describes an impasse that posed a quandary: how to find a balance between staying in control of the treatment while being responsive to the kind of object the child needs the therapist to be—being empathic without being intrusive—and meeting her aggression without getting into a power struggle. The author discusses how asserting her subjectivity by playfully role-playing aspects of the patient, by spontaneously using humor, and by surviving her destructiveness allows the treatment to move forward. Trial and error, reflection on practice, and informed intuition contributed to the author's understanding of the child and of the transference. Various theoretical perspectives influenced the work.     

Commentary on Paper by Françoise Davoine

Françoise Davoine sees madness as a research project involving the uncanny presence of ghosts arising from the realm of the transference as well as the “big” history of wider social catastrophes across the generations, in effect “cut-out” pieces of the unconscious. Madness is a rupture in the social link that needs repairing. The therapist is a coresearcher with the individual whose madness tells a story embedded in the heart of madness itself. Davoine presents her work with a woman who has a history of multiple psychiatric hospitalizations. She invites her patient to link up with and speak of that which formerly resided in the Lacanian Real, that is, the unsymbolized haunting absence of her mother who was tragically murdered by the Nazis. The therapist's dream becomes a bridge to this world of ghosts for both patient and therapist. The dream ushers in an enactment and a transference interpretation by the therapist, which leads to a disappearance of madness from the analytic stage. I attempt to apply the theories of Post Kleinians, as well as Harold Searles and Gaetano Benedetti, to help illuminate the processes of therapeutic action. Contemporary psychoanalytic approaches to dreams and a relational view of madness are also addressed.     

Nameless Desire: Alexithymia and the Anorexic Patient

In this article, the author attempts to provide a psychoanalytic understanding of the anorexic patient who is disconnected from her affective experience and is considered to be alexithymic. Through her restrictive food ritual, this type of patient may organize her internal states by repeatedly creating an illusion of what it is that she needs and desires. The author asserts that the task of the therapist working with the anorexic patient with alexithymia is to be aware of his own sensation-based reverie as lived within the intersubjective arena. This will enable the therapist to assist the patient in building an affective vocabulary to accurately identify, differentiate, and label the internal signals of her body. It is suggested that the subjective emotional experience of the patient will continue to be reorganized, expanded, and enriched as the therapist and patient mutually influence one another in this unique relational matrix. A clinical vignette is provided to illustrate intersubjective treatment interventions with a difficult-to-reach anorexic patient.     

What Are We Doing There? A Therapeutic Tale

In this paper I try to portray our interpsychic work as reflective of an infinite conversation: an intersubjective dreaming of one’s life, moving between multiple positions/self-states, those of the patient and our own; becoming involved while pondering the movement we are part of, sometimes in our hearts and minds, many times aloud and openly with our patient; recognizing her experience and enabling her to see us, and sometimes not reflecting at all—“the “moving talk.” The dilemma of the therapist’s positioning, internally and interpersonally, is further postulated, especially in regard to the posttraumatic patient who suffered severe childhood abuse.     

Coping with the Angry Patient

This patient is enacting two chronic maladaptive patterns. In one he alternates between the role of victim and abuser while inducing the therapist to play the counterrole. He tries to master the abuse he suffered passively as a child by becoming abusive with the therapist and having her experience what it feels like to be mistreated. My effort would be to interpret this pattern even while acknowledging and absorbing some degree of his anger. In a second pattern he acts like an angry, demanding child in an effort to extract nurturance and special treatment from the therapist. I would help him explore this posture in terms of his deprived background and its maladaptiveness in his current life. Finally, I present vignettes from my own practice to demonstrate how I work with patients' anger when it is expressed indirectly rather than in Mr. P's very direct manner.     

The Interplay Between Therapy and Supervision

This paper examines the relationship and interplay between therapy and supervision; and how the therapist who has particular similarities to the patient brings her own armentarium of defenses as well as life problems into the therapeutic and supervisory space. The paper explores how unconscious factors from childhood become reenacted in the therapeutic space and produce emotions that affect both patient and therapist. The paper describes in detail an upward as well as downward parallel process acted out by the therapist and patient in the transference–countertransference encounter along with the supervisor's conscious and unconscious role in this process. The paper concludes by offering recommendations to beginning analytic therapists.     

How to Help a Thin-Skinned Person: Commentary on Paper by Stephen Seligman

Stephen Seligman's treatment of Harriet illustrates the typical challenges and basic technical principles in working with narcissistically sensitive people. Often, with such patients there are struggles around the frame, especially issues of payment and cancellation policies. Sometimes the therapist must be flexible in negotiations with the patient. In the early phases of therapy interpretations of defense, especially the interpretation of projected aggression, are not helpful. Interventions that recognize the patient's response to something the therapist has done or failed to do are more effective and set the stage for later work focused on the patient's recognition of her self-states. A willingness to respect Harriet's identification with Joan of Arc, and to work in displacement, rather than pathologizing her preoccupation was also essential. Finally, Seligman utilized the concept of mentalization in actively discussing with Harriet the mental processes of other people in her life. All these techniques enabled Harriet to move from being dominated by a sense of grievance to becoming capable of experiencing grief.     

A Complicated Friendship

The author presents a complicated friendship with a woman who helped to raise her children. As a feminist therapist, the author is aware of the non-egalitarian nature of an employer/employee relationship, resulting in a complicated friendship. She discusses the valuable lessons she learned from her comadre (co-mother or allomother) on poverty, Latino culture, and immigration. The author applies these valuable lessons to her work as a feminist therapist, supervisor, and teacher.     

Addictive states of mind

This paper explores the meaning of the pregnancy of the therapist as a challenge to the maintenance of the setting for therapy. The patient I shall describe was born ‘black’ in a ‘white’ family and was thus a challenge to her father's sense of paternity and her parents as a couple. She was the visual evidence of an infidelity. The problem had been denied in various ways, going as far as the attempt to deny her very existence. The therapist's pregnancy signified a betrayal of the ideal of a stable setting which was compounded by an earlier absence through illness. This ‘breaking of rules or promises' was then the setting for a re-working of the patient's story.

Setting, it is argued, can helpfully be seen as the mental space created by the partnership within the therapist between maternal and paternal relating to the ‘baby’ of the therapy. This enables a sense of negotiation and relationship in the creation of setting, which can include disruptions and other babies. At the same time the therapy had to work with a fundamental issue of illegitimacy or lack of belonging and the therapist's response to this. The ‘rules' of setting are a means to ensure a place to belong or attach to, but this work emphasized ‘setting’ and belonging as issues of relationship supported and enabled by our rules of engagement, but not reducible to them.     

Toward Holistic,Compassionate, Professional Care: Using a Cultural Lens to Examine the Practice of Contemporary Psychotherapy in the West*

The author describes work undertaken in New Delhi with two young Indian women and their families from 1995 to 1999. Both presented with depression and suicidal ideation. One was severely cerebral palsied, the other was diagnosed with endogenous depression. As an integrative therapist, the author looks at her work from several perspectives. The debates highlighted here focus on the optimal usefulness of each of these perspectives in different situations, both the benefits and the limits and the very limits of contemporary psychotherapy itself. The author uses a cultural lens to explore the use of the self of the therapist and issues around boundaries, continuity, ethics, and compassion in psychotherapy.*Part of this work has been published in N. Hutnik (1999). An unusual intervention: Disability and abuse. Psychological Foundations - The Journa1, 1, 81–84, and is reproduced here with the permission of Psychological Foundations, New Delhi.**My heartfelt thanks are offered to Reenee Singh, friend of many years and very competent family therapist, who offered me her comments on an earlier draft of this paper.     

Rebirth fantasy and the psychoanalytic process

In this paper, Jungian and Freudian perspectives on the fantasy of rebirth are explored and a brief review of the literature on the theme is used to show how that the rebirth fantasy seems to be a universal fantasy in the human mind, connected with the experience of both destruction and creation. In the psychoanalytic process the rebirth fantasy is connected with initial hopes for a better life, but is also a vehicle for creating the analytic pair and for separating from the 'totalitarian object'. An account of clinical work with a patient is given to illustrate the mutual and parallel process of rebirth in both the patient and the therapist. For the patient, the therapy was experienced as an awakening or a birth. The therapist was initially doubtful about the patient's capacity to engage in the analytic process but his involvement and interest were 'born' during the early sessions, enabling the patient to rely on him to lead her out of the claustrophobic power of the totalitarian object.     

The Risks of Therapist Passivity and the Potentials of Constructivist Influence

Francesca Colzani’s rich report of her sensitive work with Elisa highlights the therapist’s struggle with the issue of the exercise of power and authority bearing on the patient’s choices. It is suggested that sometimes the analyst poses her dilemma in dichotomous terms, choosing, in effect, between coercion and passivity. Also, it is argued that moral choices can be obscured by a turn to medicalization, diagnosis and treatment, of the patient’s “condition.” An alternative is proposed in which the analyst may offer constructive suggestions imbued with her subjectivity—her experience of conflict and uncertainty—leaving Elisa room for the exercise of her own responsible agency. In finding her own voice, the analyst may awaken selves or aspects of self of the patient that might otherwise remain dormant, potentially to her detriment. An example of an interpretation of projective identification, with self-disclosure on the analyst’s part, is proposed that might encourage collaborative reflection on a seemingly dissociative dimension of Elisa’s way of being and relating.     

The Powerless Therapist and the Helpless Borderline: Acceptance,Aloneness, and Dyadic Joining

The encounter between therapist and borderline patient brings with it a humbling experience of powerlessness. The therapist or helping agent must confront her or his own feelings of inability to change anything in the patient's mental or material life. With this comes a corresponding reality that the locus of therapeutic action remains very circumscribed indeed. Many therapists, particularly new ones to the field, may feel overwhelmed by anxiety, grief, guilt, and fear, tempting them to jump precipitously into interpretations or thinly veiled advice-giving—or, alternatively, to deflect emotion with hollow “empathic” mirroring. By actively getting in touch with and using his or her experience of powerlessness, however, the therapist can find a way forward that relies on dyadic joining and a more useful conception of the therapist/patient system (whose dynamics, as we will see, are also increasingly clarified thanks to emergent neuroscience findings). Central aspects of this approach have been present since borderline first appeared in the literature, continuing through more recent contributions, notably those of Marsha Linehan and the Dialectical Behavior Therapy (DBT) school.     

On Psychodynamic Meanings of Psychiatric Treatment: Discussion of “From Dyad to Triad”

Dr. Bar-Haim has covered vast territory in her contribution “From Dyad to Triad: On Psychodynamic Meanings of Psychiatric Treatment,” (this issue) and I welcome the opportunity to offer my thoughts on her contribution and this important topic more generally. The issues touched upon include the various meanings of psychiatric treatment for patient and therapist; factors that impact compliance; resistances to suggesting medication consultation on the part of the therapist; challenges of the prescribing therapist; the role of a “disease” model in mental suffering; the overdetermined meaning of “symptom”; and, most important, recommendations for establishing effective treatment when a treatment triangle exists. I address some of these issues and comment on two clinical vignettes to illustrate my way of thinking.     

Revenge of the fathers Incest and the male therapist

Abstract

This paper argues that the socio-psychological foundation of incestuous relations between father and daughter resides in the primordial rivalry between father and son and is a manifestation of the property relations existing between them throughout the period of patriarchy. After an attempt to trace this rivalry along a path through Western civilization by summarizing evidence from both religious and mythological sources, I introduce it into our own times by using two case illustrations from my own clinical work. Here I claim that when a male counsellor/therapist engages a sexually abused female patient he, at the same time, encounters the incestuous father in a potentially rivalrous struggle over the patient. For genuine healing to take place in the patient, the counsellor/therapist must form an alliance with the father and utilize his hidden value in enhancing his own therapeutic capability.

I began by stating that particular clinical complexities exist when male therapists engage with female clients who have been the victims of paternal incest. I then postulated the idea that the socio-psychological foundation of such relationships is the primordial rivalry between father and son and is in fact a particular manifestation of the property relations existing between them. I then traced this father/son rivalry along its path down through Western civilization via Jerusalem and the Judaic/Christian religions, and Athens with its early creation myth, and the somewhat later myth of Oedipus. I then pursued the course of its influence to our own times, to the incestuous father/daughter relationship, and, using examples from my own clinical work, I attempted to show how this father/son rivalry survives as a powerfully pervasive influence in the clinical relationship between the female patient who has experienced paternal incest and her male therapist.     

Incognito or not? the patient's subjective experience of the analyst's private life

This paper examines the meaning for the patient of the analyst's personal life and personality which are ostensibly banished from the consulting room. The therapist has a not‐always‐so‐secret “secret life”; that the patient is supposed to “not know”; about. Yet, more or less unconscious perceptions, impressions, and fantasies about extratherapeutic aspects of the analyst are omnipresent and significantly color the psychoanalytic enterprise.

Moreover the analyst as a person generally plays a critical and underacknowledged role in the patient's experience of the endeavor. Constructing multiple overlapping images of the analyst and of the analytic relationship, the patient discovers himself or herself in the matrix of these relationships with various images of the analytic other. The analysand is motivated to make sense of the analyst as wholly as possible, the better to place into context the analyst's interventions. The patient's resulting view of the analyst's subjective experience acts as a lens that filters and subtly alters the meaning of the analyst's communications.

I illustrate these points by relating my work with a patient whose dreams uncannily picked up on a (consciously) unknown aspect of my private life—my having a handicapped son. The treatment thereafter centered on the patient's identification with my child (as someone “disabled") and on the meaning of her having dreamt something so personal about her therapist.