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Journal of Contemporary Psychotherapy, Vol. 26, No.

3, 1996

The Omnipotent Clinician: A Potential Source


of Iatrogenesis
Robert S. Pepper, C.S.W., Ph.D.

Clinicians who do not acknowledge their delusions of omnipotence can do harm


to their patients when these feelings are acted out in the treatment. In breaking
the frame of the therapy these clinicians inadvertent~ create the potential for ia-
trogenic treatment reactions. When practitioners knowingby practiced outside the
boundaries of the established wisdom and theoretical knowledge of the profession,
an ethical problem arises. Under such conditions, it can be said that the practi-
tioner consciously jeopardize his patients emotional, and at time, physical well-
being. Justifying their behavior, some therapists ironically assert that they are
morally superior to others who adhere to the rules of treatment. As Langs note,
when boundaries are blurred therapists often unconscious(y dumps their pathology
into the patient who must then struggle to contain the toxic feelings of both parties.
Resolution to this ffpe of countertransference may come through greater awareness
of the therapeutic community at large as to the dangers of acting out feelings of
omnipotence in the treatment.

INTRODUCTION

One of the most unequal of all adult social relationships is that of


patient to therapist in analytic psychotherapy. Inequality exists in the pro-
fessional therapeutic relationship for at least two reasons. First, the nature
of the healing process requires the patient regress. The patient, by defini-
tion, is subordinate deferring to the clinician's expertise and skill. As a con-
sequence, the patient is vulnerable to psychological mistreatment. The
clinician must be trusted to place the patient's needs first, anything less
would constitute an abuse of power. However, not all clinicians can be
trusted to place patients' needs first. As Robert Langs notes, there are some

Address correspondence to Robert S. Pepper, 110-50 71 Road, Forest Hills, New York 11375.

287

@ 1996 HumanSciences Press, Inc.


288 Pepper

therapists who unconsciously harbor destructive thoughts and feelings to-


wards their patients, and allow this negativity to enter the treatment (Langs,
1989). This then leads directly to the second potential source of inequality
in the professional treatment relationship: the therapist's own personality
and its exploitive impact.
For example, clinicians who do not acknowledge their "delusions" of
omnipotence can do harm to their patients when they act out these feelings
in the treatment. There are some therapists who consciously act outside the
bounds of established wisdom and ethics in the field. These clinicians often
believe that they are immune from the dangers inherent in breaking the
frame of the treatment. My research has shown that some therapists delude
themselves into thinking that they are more psychologically sophisticated
than theft colleagues and are thereby capable of behaving unethically with-
out regards for the consequences (Pepper, 1991). Sadly for their patients,
these practitioners may be right. Their grandiosity, coupled with the natural
insulation inherent in the role of therapist, can shield them. It is the patient
who must bear the brunt of blurred boundaries in treatment (Pepper, 1990).
Omnipotent clinicians tend to justify their disdain for ethics and
boundaries by claiming moral superiority over their peers whom they see
as rigid and unfeeling (Temerlin and Temerlin, 1982). This type of thinking
is at best naive, and at worst, potentially iatrogenic, as we shall see in the
next section of this paper.
This article addresses the clinical and ethical impropriety that exists when
an analytically trained clinician knowingly functions outside the boundaries of
the wisdom and knowledge of the profession. According to the American Psy-
chological Association's Guidelines for Ethical Standards, it is the responsibility
of the psychologist to be sensitive to the "differences in power" and particularly
personal limitations and "the effect of those on their work" (Code of Conduct,
1992). Further, clinicians are bound "to recognize personal problems and con-
flicts" and "be alert to the signs of, and obtain assistance for their personal
problems at an early stage "(Code of Conduct, 1992). In addition, a clinician
is responsible for ensuring that patients are not used for personal gain. How-
ever, the omnipotent therapist is generally not sensitive to these ethical con-
cerns. In fact, for the purpose of this paper, the omnipotent clinician is defined
as one who displays an oblivious and often contemptuous attitude toward ap-
propriate boundaries and a disdain for those practitioners how observe them.

Freud, Deutsch, and Tausk: Boundary and Responsibility

Research seems to indicate that the omnipotent therapist tends to


flaunt rules of extra-treatment contact, and fees referrals and advice-giving.
The Omnipotent Clinician 289

Further, there is a tendency to misuse the transference, countertransference


and resistance to justify outrageous violations of the frame of treatment
(Pepper, 1991, 1990).
Perhaps one of the most famous examples of this phenomenon comes
from Sigmund Freud's own inner circle, the case of Victor Tausk and
Helene Deutsch. Freud's view that countertransference is "what arises in
the physician as a result of the patient's influence on his unconscious feel-
ings" (Freud, 1910), may have shielded him from having to accept some
responsibility for compromising the treatment of Deutsch and Tausk, and
Tausk's subsequent suicide.
Tausk was Freud's student and intellectural rival. They were competi-
tors in the psychoanalytic circle of that era. When Tausk approached Freud
to analyze him, Freud refused. Instead Freud referred Tausk to Helene
Deutsch, who was simultaneously Freud's patient and student and one of
Tausk's junior colleagues. Tausk reluctantly accepted the referral and pro-
ceeded to spend his sessions complaining to Deutsch about Freud. Deutsch,
in turn, used her sessions with Freud to complain about Tausk. When Freud
decided to put the triangle to a halt, he gave Deutsch an ultimatum to
terminate Tausk as her patient, or end her analysis with him.
Not surprisingly, she terminated treatment with Tausk. Shortly there-
after, Tausk killed himself. While Tausk's troubles were not all Freud's do-
ing (Tausk was engaged to be married to a former patient of his at the
time of his death). Freud's behavior was clearly deleterious to both Deutsch
and Tausk.
That Freud took no responsibility at all in Tausk's suicide was revealed
in a letter to a friend about Tausk: where he wrote, "I confess I do not
really miss him; I had long taken him to be useless, indeed a threat to the
future" (Roazen, 1974, p. 321).
It is possible to conjecture that Freud's disregard for appropriate
boundaries may have been fueled by an unconscious wish to get rid of his
rival, Tausk. Given Freud's status and grandiosity it is possible to imagine
Freud thinking that he could do anything without consequence. That Freud
analyzed his own daughter, vacationed with patients and generally did not
adhere to his own rules of analysis are widely known: As Roazen (1974)
noted;
From Freud's point of view, there were good reasons for doing what he did. The
rules he set down in his papers were. not intended for himself, and he did not
expect his students to follow them too closely either (Roazen, 1974, p. 439).

Surely, Tausk and Deutsch were ultimately responsible for their own
choices. One can only imagine the enormous pull toward unconscious grati-
fication that must have been exerted so close to the master's feet. The wish
290 Pepper

to be emotionally fed by Freud and the fear of displeasing him, may have
blinded both Deutsch and Tansk to the dangers of blurred boundaries.
In a previous paper, I described the seductiveness of these types of
incestuous arrangements in the psychoanalytic community (Pepper, 1990).
Under such conditions, the demarcation between reality and transference
can become so diluted as to render the analysis hopelessly contaminated.
To believe that one is beyond the dangers of blurred boundaries simply by
virtue of one's brilliance is an act of hubris.
In the following example, the work of a contemporary clinician is pre-
sented. Once again issues of blurred boundaries and the contamination of
the treatment seem to be directly linked to the personality and character
of the therapist. This case posits a particularly thorny ethical issue, since
the clinician consciously decides to operate outside the bounds of the wis-
dom of the field.

CLINICAL VIGNETTE FROM THE TABOO SCARF

In the preface to his bestseller, The Taboo Scarf, George Weinberg


acknowledges the need for confidentiality in protecting the identities of the
private patients he writes about in this collection of case studies "as prac-
titioners must when they write about their work, I have altered these stories
to make them unrecognizable" (Weinberg, 1990), p. vii). However, the first
chapter entitled, "The Beacon" is about a severely depressed young woman
who is the daughter of a former girlfriend of his.
It would seem that the incestuous nature of this connection to his
patient makes the identities of both mother and daughter easily recogniz-
able, thereby constituting a breach of confidentiality. The case is further
confounded by Weinberg's assumption that his feelings for his former girl-
friend can somehow remain at bay and not negatively influence the treat-
ment and his professional judgment.
Weinberg begins the chapter by telling the reader of his initial con-
sultation with this ex-girlfriend, Susan, who urged him to treat her daughter.
In musing about Susan upon seeing her in his office, he says: "maybe I
was still in love with her. But she was in my office for a consultation, and
that was that." (Weinberg, 1990, p. 5). Weinberg, in conflict as to whether
to take the case finally relents: "What? A relationship twenty-five years
ago stopping me from working v/ith someone else!" (Weinberg, 1990, p.
8). Incredibly, he seems to think that the unconscious mind is constrained
by time and that old feelings toward his ex-girlfriend will not effect his
relationship with her daughter as a patient. He decides to charge the girl-
friend for the consultation only if the daughter agrees to treatment. Sadly
The Omnipotent Clinician 291

for the patient, the negative consequences of this wild arrangement are
apparent in their way first session.
The patient, Lisa, makes what seems to be an oblique reference to
him when she describes her feelings about doctors: "I hate doctors they're
all ugly, really" (Weinberg, 1990 p. 12). Weinberg tries to reassure her that
he only wants to help but he seems to miss the unspoken message that
Lisa is communicating.
In compromising that treatment through blurring the boundaries, he
has lost considerable leverage as a therapist and has created a situation of
mistrust (of his motives) that no amount of reassurance could assuage. The
patient unconsciously knows she is in danger but is helpless to verbalize
this awareness directly. Instead, she tells him indirectly about her feelings
toward him through her reference to feelings toward doctors.
My interpretation of this episode appears consistent with Robert
Langs' theory of deviate frame therapy (Langs, 1989). Langs believes that
patients are exquisitely sensitive to violations of the frame of treatment but
are not able to directly respond. Instead, patients communicate symbolically
through encoded messages and dreams. Amazingly, Weinberg's description
of what appears to be bizarre digression by Lisa, is actually a predictable
response to a frame violation according to Langs' theory. Lisa asks him,
apparently out of nowhere "Did you know that termites, when they're un-
der attack, create more soldiers than usual? In one week, they give birth
to ten percent warrior termites instead of two" (Weinberg, 1990, p. 14).
Weinberg encourages Lisa to describe the details of the termite behavior,
apparently thinking that this is only a metaphor for Lisa's relationship to
her mother who is characterized as the "queen termite." However, it might
also be that Lisa's presentation is an example of what Langs calls iatrogenic
paranoia which is "reflected in stories of spies, intruders, unwanted com-
pany, inept people who can't function for themselves and so on" (Langs,
1989, p. 123). Lisa says that her job is to protect her mother from intrusive
men. Given the incestuous nature of the relationship between Weinberg,
Lisa and her mother, it would seem that Lisa may in referring to him.
Weinberg himself appears to confirm this conjecture. In pressing Lisa for
details about Susan's life, he admits" in retrospect, I'm sure I would have
asked, even if I'd had no residue of curiosity about Susan and the way she
lived" (Weinberg, 1990, p. 15).
Perhaps the most glaring disregard for the ethics and wisdom of the
profession appear in an episode in which Weinberg gives Lisa money so
that she can take her sick cat to the vet. Weinberg, apparently aware that
some readers might have a problem with this, responds to his unseen critics
by using an ad homonym argument. Rather than defend his position on a
theoretical basis, he justifies his behavior by contemptuously dismissing
292 Pepper

ethical practitioners as "despicable precisionists" with character flaw - He


thus writes.
To this day, it has never crossed my mind that my offer of money would have any
countertherapeutic element. How despicable are the precisionists in psychology who
care more about the operation than the p a t i e n t ! . . . h a d anyone I knew thrust forth
a cat in a near death state and proved that I was its only hope, I would like to
think I would have done the same (Weinberg, 1990, p. 25-26).

It seems significant that Weinberg sees himself as the cat's "only


hope." Assuming Lisa's resources were limited, he takes at face value her
assertion that her mother would not help. Weinberg's generosity maybe im-
part the acting out of his sense of grandiosity and competitive feelings to-
ward Susan. In uncritically accepting Lisa's story, Weinberg might be
playing out a rescue fantasy that actually undermines the treatment. Lend-
ing Lisa money interferes with the development of the negative transfer-
ence which would be critical for Lisa's cure. In placing gratification above
analysis Weinberg could be doing more harm than good. Langs has noted
that the giving of a gift by the therapist to the patient is unconsciously
perceived as damaging: He notes that this behavior
It blurs the boundaries between patient and therapist, and ultimately deprives the
patient of what is needed from psychotherapist. At the very moment that a therapist
gives a patient a gift, the deep unconscious system experiences a dramatic sense of
deprivation, loss and harm, (Langs, 1989, p. 187).

Weinberg engages in a spurious defense of his position when he ac-


cuses ethical practitioners of being uncaring "precisionists." Without a theo-
retical orientation or data to support his decision to deviate from
established principles, he veers from a scientific debate on technique. Char-
acter assassination substitutes for an analytical and honest, and critical dis-
cussion of the pros and cons of breaking the frame of treatment.
Further, by claiming moral superiority, Weinberg may be overlooking
the potential iatrogenic consequences of giving Lisa money. While con-
sciously trying to help, he may actually foster a pathological dependency
of the patient upon him. Turning therapy into "not therapy" magnifies the
power differential in the relationship which thwarts the patients therapeutic
need to openly express anger toward him; that is, to develop a negative
transference. Indeed, the transference becomes reality which only serves
to increase her unspoken resentment toward intrusive and manipulative
men in her life. The act of gift giving, in this case, may be viewed as a
form of projective identification which Langs has labelled as "dumping"
(Langs, 1982). According to Langs, dumping occurs when therapist deposits
his own pathology into the patient who must then struggle with the denied
and projected feelings. Here, Weinberg dumps his feelings of helplessness
and rage toward his girlfriend into his relationship with his patient, her
The Omnipotent Clinician 293

daughter. The giving of money frees him from feeling helpless and provides
a false sense of power. However, Lisa is left in the unenviable position of
having to contain the feelings of impotence that both she and Weinberg
share in relation to her mother. In other words, the clinician's narcissism
is gratified at the expense of the patient's need to separate and to struggle
with life's problems autonomously.

SUMMARY AND CONCLUSION

The prime dictum of any professional code of ethics is: "above all
else, do not harm." However, the clinician who acts on feelings of omnipo-
tence in the treatment, can do harm. Such therapists often believe that
they can breach the boundaries without consequence. Therein lies the dan-
ger.
The rules of analysis protect everyone, the clinician included. Adher-
ence to the frame minimizes the potential for the most destructive forms
of unconscious contamination from entering the treatment. While adher-
ence to the rules alone does not necessarily guarantee good therapy, it
seems that violation of the frame increase the risk of iatrogenic treatment
reactions.
Clinically, the valuation of gratification above analysis that is often
reflected in breaking the frame of the treatment, robs the patient of the
therapeutic need to experience the fully intensity of the negative transfer-
ence. Even under ideal conditions, patients tend to protect the therapist
from the extremes of their angry feelings. When the patient is overly grati-
fied through a deviation of the frame, there is a greater tendency for the
patient to disown these negative feelings. But these feelings do not just
disappear, what often happens is the patient acts these feelings out in their
life, or they act them in, in the treatment through some form of treatment
destructive, or self-destructive behavior.
Omnipotent therapists do not often see the connection between their
own behavior and these types of resistances. Herein lies an ethical danger
of acting out omnipotent feelings by the clinician. The therapist who breaks
the frame of treatment is under moral obligation to be alert to any regres-
sion on the patient's part and to be prepared to determine the extent to
which the regression is iatrogenic. If the clinician is unwilling to consider
this as part of the problem, then patients are in great danger. When pa-
tients are held responsible for all impasses in treatment, serious decom-
pensation can occur (Temerlin and Temerlin, 1982). The need for
boundaries then is the need for accountability. In breaking the frame the
294 Pepper

omnipotent clinician forfeits the right to interpret resistance as purely trans-


ference.
Sadly, therapists of this ilk are not generally inclined to accept this
responsibility. Since patients are too vulnerable to provide the appropriate
feedback, it would appear that the onus is on other professionals. Profes-
sional organizations such as the American Group PsychotherapyAssociation,
which sponsors yearly workshops at the annual convention, keep the spot-
light on the potential hazards of blurred boundaries in treatment. While
omnipotent clinicians do not usually participate in these workshops, ethical
therapists who attend gain insight into the often subtle nature of the prob-
lem and return to their practices and other professional affiliations with
increased consciousness and motivation to spread the word to others. In
this way, the psychotherapeutic community at large is that much more safe-
guarded from the entopic pull toward chaotic and destructive treatment
relationships.

REFERENCES

American PsychologicalAssociation (1992). The Ethical Code for Psychologists.Washington,


D.C.: American PsychologicalAssociation.
Freud, S. (1910). The futureprospectsof psycho-analytictherapy.Standard edition.
Langs, R. (1982). The psychotherapeuticconspiracy.New York: Jason Aronson.
Langs, R. (1989).Ratingyour own therapist.New York: Jason Aronson.
Pepper, R. (1990). When Transference Isn'tTransference:Iatrogenesisof Multiple Role Re-
lations.Journal of Contemporary Psychotherapy.20, 141-153.
Pepper, R. (1991). The Senior Therapist'sGrandiosity:Clinicaland Ethical Consequences of
Merging Multiple Roles Journal of Contemporary Psychotherapy,21, 63-70.
Roazen, P. (1974).Freud and his followers.New York: Meridian. Temerlin, M. & Temerlin, J.
(1982). Psychotherapy Cults:An iatrogenicperversion.Psychotherapy,40, 131-140.
Weinberg, G. (1990). The taboo scarf,New York: St. Martin Press.