Revictimization/ Power Imbalance/ Alternatives
I would like to begin by stating that I believe that there are many well-qualified, competent psychotherapists currently in practice. My objective here is to attempt to highlight actual as well as potential abuses of power in the treatment setting which can result in the revictimization of an already traumatized client. I believe that survivors, as well as any other type of mental health consumer, should be empowered by becoming aware of their rights in the therapy as well as in the hospital setting. By becoming empowered, I believe that the imbalance of power that currently exists in the therapist/client relationship can be shifted, resulting in the client becoming a more active participant in his or her treatment.
I believe that most of you know that the history of the hospitalized "mental patient" has not been free of degradation, stigma, and frequent abuse. Masson (1994) points out in "Against Therapy" that 300,000 mental patients were killed or exterminated during the Holocaust prior to the extermination of the Jews. I would like to say that we have come a long way in the advancement of humane treatment in the hospital setting. Unfortunately, I do not believe that many advances have been implemented. Certainly, unlike the 1800s, when fathers could drag their daughters to a "benevolent sanitarium" to spend approximately 40 years of their because of a somewhat popular disorder termed "moral insanity" which meant that these daughters did not want to live their lives the way their families thought they should we do have stricter criteria for involuntary admissions to psychiatric units. These criteria are that an individual must be deemed either a danger to him or herself or to others. These criteria, strictly adhered to, would presumably mean humane rescue for the person afflicted with uncontrollable suicidal or homicidal urges. I question, however, whether treatment is uniformly humane, and, if one reads books such as "Asylums" by Goffman (1961) which addressed the state of institutionalization up to 1961, or "They Call it Help" by Louise Armstrong (1993), which examines more current psychiatric hospitalizations, the question does arise as to whether any form of psychiatric hospitalization is, in fact, humane. Certainly, enforced frontal lobotomies, ECT treatments, forced and prolonged restraint and/or isolation do not seem to fit the definition of "humane", but, in fact, define the opposite blatant abuse.
Not all voluntary or even involuntary admissions result in the types of treatments mentioned above. However, the hospital is an institution that must maintain order and promote healing of the clientele, while assuming responsibility for that clienteles safety. I question the priority-setting policies of any large institution, particularly psychiatric hospitals and units. I had the dubious pleasure of being hospitalized for 6 ½ months in 1986, an admission which was supposedly a voluntary one, and the unit was purportedly an open one, which meant that one could walk around the grounds unescorted, and no doors were locked. Without going into too much detail about my own experiences (could write an entire book about them!), I do want to comment about the practices that became immediately apparent, and which made me realize that maintaining order was the number one priority for this hospital. Not long after I arrived, a young girl was yelling in her room. There were about four attendants or mental health workers with her. All patients were ordered off the floor, and the girl was put into a camisole, and dragged to another unit where she could have time out and medication. Now, I wondered why it was wrong to yell. It was obvious that this girl was angry, and she was not violent, but was behaving like anyone else who is very angry. People often yell. I also thought that, if one were not angry prior to the hospitalization, it was normal to become so afterward as so many of the rights of the average adult are removed once one is admitted as a patient. For instance, one could not have toiletries in his or her room, nor lock the bathroom door, nor use the phone for several weeks, and then on a restricted basis, nor hug another patient in distress, and most certainly could not light ones own cigarette; this, in addition to knowing that ones room could be searched at any time without warning. If one did not strictly adhere to rules, then one could not walk on the grounds, one could not leave the building, and often one could not leave the floor.
After this girl was escorted in the strait jacket to the "quiet room", we had a community meeting. Patients were asked if they were distressed. Yes, we were. It was said that the camisole was a source of comfort. I asked if the particular therapist making this statement had ever been in one. She said, "No". I then asked, "Then, how do you know?". We were advised that it was in the best interest of the unit and the girl to take her off the unit. What it told me was that we had better not get angry in a verbal way because the same fate would result for us. Now, many of us have problems with anger, and this incident made anger seem very threatening.
I am bringing this particular incident up because I wish to point out that basic human rights do not seem to be available to one in the hospital. This, to me, is abuse, although not as brutal perhaps as ECT or being beaten, but abuse nonetheless. A patient does not feel equal to the staff, and the overriding feeling is that the staff can do anything they want to you by virtue of the fact that they are in charge. And they can, because "privileges" can be revoked if one does not demonstrate compliant behavior. Jeffrey Masson (1994) holds a belief that I share that the healthiest patients are the ones who do not comply (at least inwardly), but who see the institution for what it really is. It is to enforce a certain acceptable code of behavior upon the patient. What is considered acceptable is up to the discretion of the hospital staff.
This is not to say that some people cannot be helped by brief hospitalization when they have uncontrollable urges to self-harm, for instance, but even in this case I personally know some who have successfully injured themselves while under the watchful care of hospital staff. The point here is that perhaps the profession, as well as clients, should examine the goals and actual treatment that a particular hospital offers. It is my guess that the professed goals and the treatment reality radically differ in many, if not most, cases, and that the primary concern of the hospital, aside from the money-making potential, would be revealed to be the promotion of maintaining order. It is my opinion that every human being is entitled to respect, basic human rights, and to be viewed as a competent, or potentially competent adult. It is not respectful to be treated as a child when one is an adult, and the removal of rights taken for granted in the outside world is not only infantilizing, it is also punitive. It is as if the operating rationale is that one should be punished for being an individual who might opt for a safe environment while attempting to work on painful issues. I have not been re-hospitalized, and the overriding reason is there is a very strong desire never to be subjected to this form of treatment again.
Does this mean that the hospital worked? I certainly dont think so. The infantilization, combined with the intrusive and demeaning environment made me feel as if I were in some ways reliving my childhood, when there were no rights, and when there was extreme invasion of my body and privacy. Fortunately, when I had had enough of the treatment that "was in my best interests" I had the "right" to walk out the door undetected, remaining undiagnosed, but finally free. I "eloped".
Another form of psychotherapeutic hospitalization is the Therapeutic Community (TC) that is designed to rehabilitate hard-core drug addicts and sometimes alcoholics. The treatment in these communities consists of heavy doses of humiliation, sprinkled with prolonged sleep deprivation. Residents often emerge from group meetings wearing signs such as "I am stupid" when they show indications of non-compliance, and they can often be seen perfoming menial tasks such as scrubbing bathroom floors with toothbrushes at midnight. Groups are conducted in an extremely confrontative manner, and residents can become so indoctrinated that they participate in turning each other in when they encounter non-compliance in each other. The ones who do not make it in this environment are objects of great scorn. To me, this does not indicate treatment, but rather describes an extreme form of mind control that has not proven to be effective once the resident leaves the TC.
Psychiatric hospitalization and TCs are, of course, extreme examples of mental health treatment options. Perhaps a question to ask is what brings a perspective client to the mental health community in the first place? The word I would choose to encompass all reasons is simply "pain". Pain is experienced in many ways, such as depression, anxiety, panic, drug abuse, phobias, and nightmares/flashbacks, to name a few of the presenting symptomotologies frequently encountered by clinicians. To this list, I would like to add another "symptom" which I have not seen addressed anywhere but in a book entitled "Shattered Selves" by James Glass (1993). This is the pain of the realization that one does not possess a cohesive identity. He states:
"One may choose multiple tastes and interests: one may decide for whatever reason to be different or eccentric or to hold values that counter established assumptions and preferences. One does not choose, however, to possess a multiple or fragmented identity: these effects, either in MPD of schizophrenia, are the products of a social and psychological violence that rips beings apart, terrorizes the self, and brutalizes the body. The multiplicity of identity or personality is a commentary on some of the most pathological aspects of a deranged modernity that idealizes paternal authority and the violent imposition of power".
I have not encountered a better description of the "rape of the totality of self" encountered by the child as a consequence of severe on-going abuse.
Given that the perspective client is in pain, his or her goal would seem to be alleviation of pain, or at the very least, alleviation of stressors that could be contributing to the pain. Since there are many types of clinicians to choose from, the process of obtaining relief can be a trial-and-error process. Obtaining a referral from a friend, a clinic, or even a hospital can often be of some assistance, but often the fit between client and therapist is on an individual basis. The client typically comes to a clinician with the belief that she or he will be helped, and that the professional has greater knowledge than the client in respect to the presenting problem. An uninformed client will not tend to question the professional in respect to his or her practices and beliefs, and will accept the professionals boundaries such as session times, length of sessions, the availability of the therapist in between sessions, and the clinicians fee not realizing that some, if not all, of these boundaries are negotiable. It is my opinion that, until clients become more enlightened, the burden should fall on the practitioner to inform the client of any negotiating power the client may have.
Assuming that this rarely occurs, an imbalance of power is set in place as soon as client and professional agree to begin working together. Masson (1994) is of the opinion that anyone who sets himself up to know what is normal to know what comprises human nature is a potential abuser of the client because this professional will attempt to impose his or her values on the client, regardless of how the client views herself. This scenario also promotes infantilization as the client will often become unable to assert himself effectively as the relationship progresses.
This is fertile ground for abuse. Masson (1994) reports a survey circulated in 1977 which yielded an 11% positive response to the question of whether the therapist had ever had sexual contact with a client. He points out, and I believe accurately, that these respondents are the ones who admit to this form of abuse, and that the actual percentage may be considerably higher. Additionally, he reports professionally condoned extreme physical abuses of mental patients by famous "pioneers" such as Rosen (who had his license to practice revoked in 1983) and Honig. Of course, any therapist who is ethical would probably not condone these practices. However, Masson points out that there were many followers of these "gurus", and that the profession itself will often "turn its back" on blatant abuses because of the "need to believe that practitioners are people who truly want to help the client". The client will, as a consequence, suffer in silence because of fear (of not being believed), or out of loyalty to the therapist. It is the courageous client who will come forth and file a complaint against the offending therapist. Courageous because the credibility of the client is often compromised as soon as it is known that the client has been a "patient".
These forms of abuse, are, of course, fairly obvious. If one were to define a boundary in the therapy setting as limits that allow for a safe connection based on a clients needs, then any alteration of these boundaries would yield an altered relationship, or perhaps introduce ambiguity into the therapy relationship. Some less obvious boundary violations are role reversals (client becomes caretaker); keeping critical knowledge or behavior from the client to protect the practitioner, (Peterson, 1992); misleading the client as to ones availability and to what one can actually provide in the way of support; and, violating the clients and/or other clients confidentiality.
I can identlfy with all of the above as I have experienced all violations at different times and with different therapists. I was raped by a priest who counseled me for two years during adolescence. I had a therapist who constantly talked about other clients and who talked so much about herself that I had intimate knowledge of her marital life. I later learned that she had talked about me to other clients as well. I know that I frequently felt that she should pay me, as she would ask me for advice in respect to other clients. It was when I finally asked her not to speak about herself or other clients during session anymore that she engaged in additional abusive behavior. She became very angry, placed the blame on me, and suggested that I was really angry at my abusers, and not at her. She then proceeded to engage in a pushing exercise wherein she pushed me and instructed me to push her back as hard as I could. I wouldnt push back, but I terminated with her very soon afterward.
Another therapist used my therapy sessions to talk about this former therapist in respect to possible litigation, and although I was soon tired of this, she persisted session after session. In addition, she performed an exorcism on me, which had lasting effects since I lived in fear for a while that this thing would come back. After many more signs that this woman was not even remotely as healthy as I was, I terminated with her also.
It is my belief that all such boundary violations are misuses of power. Peterson (1992) in her book, "At Personal Risk" suggests that the relationship is so structured that "the client frequently dissociates the violation or abuse because the realization would be too overwhelming". She contends that there is a double betrayal if the professional does not assume responsibility for his or her actions. Often the blame is internalized, and the client wonders why he or she permitted the abuse in the first place. Another consequence is that the client may become distrustful of professionals in general, a result Peterson refers to as "Spiritual Rape". Sometimes the ability to bond with another therapist becomes irreparably impaired, if the abuse happened often enough. It is interesting to note that, while Kluft (1990) suggests that incest survivors are particularly prone to revictimization both in and out of therapy because of what he terms "sitting duck syndrome", Peterson (1992), on the other hand, contends that victimization at the hands of authority figures is a possibility for the general population, and that all victims of abuses of power tend to dissociate the abuse.
It is Massons (1994) contention that whenever anyone seeks power or possesses power, the potential for corruption exists. I would agree with this statement and would add that anyone who purports to know more about the person than the person him or herself is demonstrating grandiosity, and, by implication, is in a more powerful position than the client if the client believes this to be so.
Martin Gross, and editor and educator, wrote "The Psychological Society" in 1978. I found his work to be credible since he is neither a clinician nor a mental health consumer, but has devoted much of his efforts to the investigation of potential societal abuses such as those found in the medical profession. He attempts in this book that therapy, as it existed in 1978 (and pretty much today) does not work in the way that clinicians purport that it does. He presents many studies to support his contentions, and the variables that repeatedly fall out as indicators of success of treatment are mutual liking and mutual respect of physical appearance and attributes between client and therapist. In other words, rapport between the two parties is what makes the therapy work, and not any one particular technique. He adds that peer support is just as, if not more, effective than individual therapy, and cites studies to support these findings. He also offers an excellent assessment of Freud. A very interesting finding is that, given the disturbances evident in Freuds psyche, Gross suggests that his biggest mistake was in "thinking and influencing others that all people were like him".
Masson (1994) was a bit kinder in his assessment of Freud as he believes that Freud differed from his colleagues in that he was willing to concede complexity in all his cases. He also thinks that some of Freuds constructs, such as the unconscious, were valuable contributions to the profession. However, he holds a very radical view that therapy cannot be genuine because, in order to have a relationship, the partners must be equal. He believes that all therapists substitute their own realities for the clients, and they thus distort the clients perceptions and actual histories. He offers no alternative to therapy, and calls for more "friendly friends" and less "professionals".
I agree with Masson, but I also acknowledge that, for some, where access to friends is limited, or who are loners in nature, a therapy relationship has a potential to be a healing experience.
I would like to suggest some safeguards when choosing a therapist, however. First and foremost, the therapist should be licensed. While licensing does not guarantee competency and/or protection from abuse, it does offer a minimal recourse to the client who encounters abuse in the therapy setting.
Second, I would like to address the notion of transference in the therapeutic setting. Transference refers to the tendency to attribute feelings a client had toward an important historical figure onto the person of the therapist. In reality, I believe that transference takes place in all settings, and, while an attempt is made in therapy to enhance the transference by the therapist offering little or no self-disclosure, this is actually a misuse of the transference as it was initially conceived (Shapiro, 1988). Freud and his followers wished to ignore history because of its nebulous reality, and, instead, they sought to concentrate on the "here and now", using interpretations of the transference paradigm as the vehicle to accomplish this goal. In addition, lack of self-disclosure does not preclude the clients ability to perceive some aspects of the therapist accurately. Finally, if one partner in a dyad holds far more information than the other about the other, the one holding the information has far more power than the one who can only guess at information. This power imbalance enhances dependency and provides a climate of potential abuse. I suggest that, when looking for a therapist, one interview and get a feel for how human the therapist seems. Is the therapist willing to engage in an equal relationship?
Third, I would encourage clients to educate themselves about the various forms of therapy available (keeping in mind that no one technique has proven to be more efficacious than another), and to be aware that they are the ones hiring the therapist, and that they therefore have the right to interview and ask questions. Sandra Hocking, in her book "Living with Your Selves" (1992), provides an excellent checklist of questions to ask the therapist. The therapist should be willing, in addition, to answer questions over the phone that are of pressing importance, such as fee and length of session.
Fourth, I would encourage the participation of clients in supervisory meetings concerning their treatment. The client should know, who, if anyone is supervising his or her treatment, and this is one way to get to know this usually "invisible" person. Supervision should be something that the client can expect the therapist to obtain, particularly at times of therapeutic "stalemate".
In conclusion, while I do not promote therapy, it is probably not going anywhere for quite some time. That said, it is my contention that therapy should become more of an equal partnership than is currently the case. An equal partnership would potentially expedite healing. Also, the burden of work and responsibility would be more equally shared, which could lessen the potential for abuse in therapy, along with lessening the degree of negative influence the therapist can have on the client. The belief that therapists have a great deal of detrimental influence on the client which is currently held by the False Memory Syndrome Foundation (FMSF) has some degree of credence since the ideal client, according to Gross (1978) is the "gullible" client. In addition, therapy as it currently exists seems to work best if the therapists values, and fantasies of the clients reality are successfully assumed by the client (Masson, 1994). An independent, client-as-partner would be far less likely to alter his or her beliefs about self and history if the power distribution were equal, and would far less likely tolerate any hint of abuse or incompetency.
(C)& (P) Ellen Edwards - 2003
Armstrong, Louise, "They Call it Help". New York: Addison Wesley, 1992.
Glass, James M., "Shattered Selves". New York, London: Cornell University Press, 1993.
Goffman, Irving, "Asylums". New York: Doubleday and Company, Inc., 1991
Gross, Martin L., "The Psychological Society". New York: Random House. 1978.
Hocking, Sandra, "Living with Your Selves". Maryland: Launch Press. 1992.
Kluft, Richard P.: Incest and subsequent revictimization in "Incest-Related Syndromes of Adult Psychopathology". Edited by Richard P. Kluft. Washington, London: American Psychiatric Press, Inc., 1990, pp. 263-287.
Masson, Jeffrey M., "Against Therapy". Maine: Common Courage Press, 1988, 1994.
Peterson, Marilyn R., "At Personal Risk". New York, London: W. W. Norton & Company, 1992.
Shapiro, David, "Psychology of Neurotic Character". New York: Basic Books, Inc., 1989.