(p. 17) Everyone I Know Knows Everyone I Know: Boundary Overlap in the Life of One Lesbian Psychotherapist
Noreen, a mid-50s European-American woman, entered therapy to deal with her attractions to women in the context of her long-standing heterosexual marriage. Our work had been rocky. What she wanted most, and complained about getting not enough of from me, focused on mirroring and validation. When I asked her to take more responsibility for her own decisions, she got mad.
Noreen had joined a number of different support groups in the lesbian community—for lesbians over 40, for fat lesbians, for lesbian artists. Other clients of mine populated each of these groups, and because discussion of one’s therapy and one’s therapist commonly takes place in the culture of several of these groups, it did not take long for Noreen to ascertain the identities of six other women who were in therapy with me. I knew this because she would often make an angry point of saying, “I know you don’t do this with Becky (or Georgia, or Alix, or Zoe), do you? I know you’re not as hard on her as on me.” My default response, “I’m wondering why you think that you’re treated differently than other people, even in therapy,” infuriated her, and it nicely skirted the topic of whether the other woman in question was in therapy with me, much less whether or not she was getting nicer treatment.
(p. 18) Noreen then began to complain about me to one of the most vulnerable of my other clients in her social networks. Zoe was struggling with the legacy of multiple real experiences of abandonment and abuse. Fearful of being kicked out of therapy because of her history, she seemed highly attuned to the possibility that a therapist, any therapist, might behave in an unjust manner toward any client. Noreen honed in on Zoe’s vulnerability, and soon Zoe’s therapy sessions became litanies of her worries about Noreen and how she believed I was treating Noreen, with the theme, “If you can be mean to her, you could do that to me, too. How do I know that you really care about me?” Behind my own mounting irritation with Noreen, I kept the boundaries firm, refocusing Zoe’s sessions on her own terrors that I might prove as deceptive in my kindness and compassion as had some of her childhood tormentors. I sought consultation from a colleague who has similar challenges in her work life—not so much for advice, more to keep myself honest in my dealings with Noreen. I worried about how these unavoidable, and for me uncontrollable, overlaps between the lives of two clients could put each one of them at risk for harm.
I found myself steeling physically and emotionally for my sessions with Noreen. I realized that I didn’t like her very much, which I could deal with. I’ve recited the study of Pope and Tabachnick about therapists’ dislike and disgust for clients to many a trainee, and I regularly sought consultation to have another eye on my risk for counter-transference acting out. But I also realized, in my discussions with my consultant, that my work with her did not seem very effective. She seemed to mark time rather than work in therapy, and I passively colluded with her in marking time. Because of the boundaries of confidentiality, I never confronted her about how her actions undermined the welfare of another vulnerable human being. In her therapy, she replicated what she had done for 30 years in her marriage: complaining, using the relationship as a rationale for acting out, never moving forward or changing. As with her husband, she had begun to act out against me, creating a relationship in which she could experience herself as the victim while engaging in minor acts of aggression. I began to think that I had a client for whom I was not doing good, but rather had the potential to do harm, and that I might need to initiate the end of our work together because I could foresee that harm and wanted to forestall it.
My consultant agreed with my perception that Noreen’s behavior constituted a parallel dance with me as it had within the relationship with her husband. She challenged me, however, on my plans to initiate termination and suggested, accurately, that I seemed prepared to banish Noreen so as to rescue Zoe from the wiles of her erstwhile friend. I felt stunned by this feedback, and I knew it was right. I felt incredibly protective of Zoe in what (p. 19) someone who knows me well calls my “mother bear” counter-transference stance. But that protectiveness could ultimately prove infantilizing, as my consultant pointed out. Noreen’s behavior had the effect of undermining Zoe’s treatment and left me unable to do as much good as I could with her. If I truly wanted to empower Zoe, it would not happen by my firing Noreen.
So I hung in with Noreen. After a while, Zoe ceased acting as her messenger, in part because she came to feel used by Noreen. I continued to maintain the fiction that I had no idea about the other woman’s identity when outside her therapy session. Noreen appointed various other messengers over time. Apparently, none of them succeeded in getting the message to me.
The following spring, Noreen began to come to her sessions drenched in perfume. For many therapists this would merely prove annoying. However, anyone who has more than a casual acquaintance with me knows well that I am chemically sensitive. Perfumes have the effect of lowering my cognitive capacities by several standard deviations and increasing my irritability to well above 8 on a 10-point scale. I tell clients about my sensitivities during the first phone call, ask that they not wear scents to our sessions, and then rarely have to deal with the issue again. Noreen apologized, she had forgotten. She “forgot” the next week, and the next. The fourth week I sent her home at the beginning of her session. Back to my consultant I went. Feeling ill courtesy of Noreen at the beginning of my working day did not simply affect me, nor did it only interfere with her session. Now, five other people each week suffered aftereffects.
My consultant suggested that I give Noreen the choice of remembering that she needed to come scent-free, or treating a scented appearance as a late cancellation for which she would pay and then leave. “No scents” was a personal boundary of mine, in place for reasons of my health and capacity to function.
When I presented this proposal to Noreen, she became enraged. “I’m in menopause, how can you expect me to remember things?” she cried. “You’re punishing me for being older than you. You’re ageist.” She stormed out, calling later that day to say that she wanted to cancel next week’s session and would call me when and if she decided to come back. The subsequent month saw several “messengers” from the group for older lesbians raising concerns about my ageism. With each one, I carefully monitored the boundaries of privacy and confidentiality, respectfully explored their worries, and appreciated their willingness to bring a difficult topic into our work. Privately, I felt anger seething at Noreen’s latest round of what was feeling like abuse of other vulnerable people, and I spent a number of meetings with my consultant ventilating. It seemed as if Noreen’s work with me had become more about how to “get” me than about making changes, and I no longer trusted her not to make me sick. (p. 20) In consultation, I came to the decision that if and when she called me back, I would decline to continue our work together, offering one closing session and several referrals to excellent colleagues.
I heard nothing directly from Noreen for about six months. Then, her voice on my voicemail: “I’d like to start seeing you again.” I waited a day and called her back. “Noreen, I’ve done a lot of thinking and consulting about our work together. I’ve come to the conclusion that what we’re doing isn’t helpful to you, and that it’s becoming more difficult for me to maintain caring and connection with you. So I’m not willing to keep working with you.” I told her that we could have a final session for closure, and that I had some referrals for her that I had also carefully considered.
Predictably, she became upset. Her anger vanished, replaced by pleading. I had helped her, I was the only therapist who had helped her, she really needed to see me, no one else…. I held firm, knowing that I would no longer have to fear having my brain taken down by her “forgetting” or spend another client’s therapy hour indirectly addressing her needs instead of those of the immediate client. She declined the final session and the referrals; I reiterated the offer and gave her the names and phone numbers of my colleagues in the letter I sent the next day.
Two days later, Zoe stormed into my office weeping. “How could you do that to Noreen? You terminated her! How can I ever trust you not to abandon me?” Now what was I going to do? I continued to owe Noreen the duty of confidentiality. I could not reassure Zoe that she had nothing to fear by telling her my rationale for my decision. I felt hugely tempted just then to rationalize that because Noreen was no longer my client, and hadn’t really been for the 6 months that she hadn’t been seeing me, I could let a little bit of detail slip about what had happened. I caught that piece of my own hostility quickly enough to keep it in check. Whatever Noreen had done, it had happened in the context of her true terror of change. I owed it to her to keep things clean, and even more, I owed it to Zoe to do that. I also owed it to myself; violating a boundary in therapy diminishes its violator, the therapist.
So I dug in for a stormy passage of work with Zoe in which she and I made use of the painful gift given us by Noreen. Zoe grieved a terrible childhood loss. She got to see me remain resolute about the privacy of everyone’s therapy. Eventually, she heard more of the story from Noreen, which evoked her protectiveness of me: “She wore perfume to her sessions with you? No wonder you kicked her out,” which then allowed Zoe to see that I would not take the invitation to demonize someone else, and that I could appreciate her care for my welfare without then sliding into a role reversal. She also found out, as did the rest of the messengers, that I took confidentiality very seriously.
(p. 21) Discussion
Key ethical issues
All psychotherapists must confront challenges to the boundaries of psychotherapy, and each one of us must sometimes straddle the delicate line between doing things that feel painful to our clients while doing our best to avoid harm. Maintaining confidentiality remains one of the most important boundaries of any therapist. Keeping that boundary and doing no harm when the lives of clients overlap, and the communities of the therapist and the client lead to unavoidable multiple roles, constitute the key ethical issues in this case.
The truism (which I helped to invent) is that therapists who are lesbian, gay, bisexual, and transgendered live in a small town no matter how large the metropolitan area of their zip code. The visible lesbian psychotherapist who writes books, gives lectures, trains other psychotherapists, and has a life in which normal life events occur lives in a particularly small town. Enter your author, who fulfills all of these criteria. Having spent my entire professional career and most of my adult life living and working in the same 20-block radius geographically, and in the heart of one of this country’s most open, vital, and active lesbian communities socially and politically, it has become one of my facts of life that everyone I know will eventually know everyone else I know.
My clients will know who has called me to try to get an initial appointment with me and discuss my response to that call in their sessions. My friends will know my clients, and my friends and trainees will be other friends’ clients, despite my best efforts to make referrals outside my friendship network. It’s a bit like living on an aircraft carrier, but with no ranks or hierarchies to create order, no rules against fraternization (except, of course, between therapist and client), and plenty of emotional distress engendered by life-long encounters with, at a minimum, sexism and heterosexism. Oh yes, and no commander of the ship who can require people to behave in a certain way.
I have navigated in these interesting waters for upward of 30 years now. Along the way I have learned some important lessons, not all of them acquired with ease and grace. My understanding of what constitutes the best interest of my clients has at times expanded as a result of their input to me about ways in which my doing the correct thing seemed mainly about covering my behind and avoiding risk. I have had to learn how to live and work effectively as a (p. 22) therapist practicing ethically with this group of people, distinct from my work with generic clients.
I do not often initiate the termination of therapy. As a feminist therapist, I tend to err in the direction of assuming that clients know when it’s time to go. Many of the people I have seen over the years have needed to feel as in charge as possible of the circumstances of their comings and goings in relationship to me because of early attachment losses and severe childhood abuse. But on the very few occasions when I have exercised my unilateral judgment about when therapy needed to end, the “everyone I know knows everyone I know” phenomenon complicated the process in ways that I had not initially foreseen.
Noreen became a teacher to whom I feel grateful. She invited me to think hard about just what confidentiality means, and how the subtleties of insuring that nothing leaks out of a therapy session are as important as avoiding blatant gossip. Interestingly, although confidentiality remains a central concern in this case, self-care is another core construct that I have come to see as I have reflected on my work with her. Seeing a consultant is a form of self-care. A consultant means that someone has my back. Psychotherapy in private practice can become lonely; with my consultant in the symbolic room with me, I had support in soothing and settling myself at those moments when Noreen acted out at her most effectively provocative.
Self-care also stood at the heart of my decision to terminate, although not perhaps in the way that would immediately spring to mind. I did in fact need to stop feeling sickened and disabled weekly. I also, and as importantly, needed not to allow myself to become a therapist who allowed herself to play first the victim of a challenging client, and then the aggressor against her in the name of interpretation or confrontation. Avoiding harm to Norine, Zoe, and all of the other women whose lives played out in that overlap meant caring for my therapist-ideal self. I could not avoid pain for Noreen unless I avoided harm to all of the people in this story, myself included. Too often, therapists stay in therapy relationships in which they allow the client to behave abusively; then they act out, abruptly terminating care or, worse, use their power to “pathologize” and shame that client’s behavior after months or years of tolerating it. That does harm to the client. That harms the therapist as well.
As I wrestled with how to be a good enough therapist for Noreen, I also had to confront the responsibility inherent in my role as a therapist whose behaviors affected an entire vulnerable population, the lesbian community in Seattle. This is not my grandiosity speaking; when small community therapists (p. 23) transgress, the toxicity trickles into many segments of those communities, and in a community where upward of 80% of its citizens will likely enter therapy at some time in their life, it’s not hard for a little trickle to get to a lot of people. Living and working in this fishbowl provides an ethics class in action almost every day.
Key ethical principles and standards
APA (2002): Principle A (Beneficence and Nonmaleficence), Principle E (Respect for People’s Rights and Dignity), Standard 2.01 (Boundaries of Competence), Standard 2.06 (Personal Problems and Conflicts), Standard 3.04 (Avoiding Harm), Standard 3.06 (Multiple Relationships), Standard 4.01 (Maintaining Confidentiality), Standard 4.06 (Consultations), Standard 10.10 (Terminating Therapy). Feminist Therapy Institute (1999): Guideline 3 (Multiple Relationships), Guideline 4E (Self-Care).
References and Further Reading
Brabeck, M. M. (Ed.). (2000). Practicing feminist ethics in psychology. Washington DC: American Psychological Association.Find this resource:
Brown, L. S. (1994). Boundaries in feminist therapy: A theoretical formulation. Women and Therapy, 13, 29–36.Find this resource:
Feminist Therapy Institute. (1999). Feminist Therapy Institute Code of Ethics. Retrieved October 23, 2008 from http://www.feminist-therapy-institute.org/ethics.htm.
Lerman, H., & Porter, N. (Eds.). (1990). Feminist ethics in psychotherapy. New York: Springer.Find this resource:
Pope, K. S., & Tabachnick, B. G. (1993). Therapists’ anger, hate, fear, and sexual feelings: National survey of therapist responses, client characteristics, critical events, formal complaints, and training. Professional Psychology: Research and Practice, 24, 142–152. (p. 24) Find this resource: