An Interview with Glen Gabbard
By Jonathan Coe
On a recent study tour to the USA, funded by the Winston Churchill Memorial Trust, I visited seven places providing specialist evaluation, rehabilitation or educational services for professionals who have transgressed professional boundaries. These services typically deal with a range of different professions, including health workers, clergy and psychological practitioners. Whilst some services use a model of treatment stemming from work with sex offenders, many are informed by an understanding of psychodynamic processes. Foremost in this field is Professor Glen Gabbard who is the Brown Foundation Professor of Psychoanalysis & Professor Director at the Baylor Psychiatry Clinic in Houston Texas. Gabbard came to public view in the US through his popular book, Psychiatry and the Cinema, and through his regular blog posts on the psychology of the TV series The Sopranos and a subsequent book on the same topic. This article is compiled from a conversation with Gabbard in Houston and a subsequent email exchange.
Evaluation and Rehabilitation
The Baylor clinic provides three day multi-disciplinary evaluations of professionals accused of boundary violations, most often involving sexualisation of the relationship, but also including financial and other transgressions. The clinic sees about equal numbers of priests, physicians and talking therapists. Gabbard notes that the majority of those assessed have either a psychiatric condition on Axis 1 of the DSM or a Personality Disorder. Sometimes they have personality traits that do not reach the threshold for a disorder but account for some of their behaviours. The clinic also sees people who are psychologically healthy but under tremendous stress. ‘Such as a middle aged guy whose wife has cancer or is dying and he may have financial problems or there may be other stressors in his life, he falls in love with a patient, the patient reciprocates and they think it's a kind of soul-mate relationship. He's not someone you would ordinarily diagnose with a psychiatric syndrome, but he's under tremendous stress.’
Do you have a structured approach in terms of assessing the potential for risk and rehabilitation?
Psychological testing is very structured, there's a whole series of standard instruments, but in my interviews I rely more on open ended questions and my sense of where the midline is in terms of responses, and what are the outliers. I worry about having too much structure. People tend to get these instruments on the internet and the clever, psychopathic guy will know what answers to say in advance.
In fifteen states here sexual contact with clients is a criminal offence. The question would be - is this guy amenable to rehabilitation? Some are and some aren't. One of things I look for in my evaluations - the simplest way to put it is 'do they get it: do they get the problem?' A lot of them say things like 'The other guys working in the hospital are so much worse than I am’. An example of this is an internal medicine doctor, he had a woman in his office who was very seductive. He said 'I can't go out with you because you're my patient'. He arranged for her to see another doctor. They went out, had sex. On evaluation he said 'I agree that I should have waited three months before I started’. He thought he was impressing me with his knowledge. He didn't get it. No understanding of the power differential. I asked whose responsibility it was in that office to avoid boundary violations ‘Obviously it's a joint responsibility, we're both adults.’ He didn't get that part either.
The other thing is to see if there is any real genuine remorse. In my writing one of the points I make is that there's a difference between narcissistic mortification on the one hand, and genuine remorse on the other. I'll ask an open ended question - do you feel bad about what's happened?' ‘Do I feel bad? Are you kidding, my life is destroyed, my family is disgraced, my career is destroyed. If I could rewind the tape I would never do this again’. And in all of this they haven't mentioned the victim one time. When I ask about harm to the victim ‘I suppose that's possible, I've read about it. But this woman was really very interested in a sexual relationship - I don't think she was harmed by it, this was what she wanted’.
Another example of not getting it, or being so narcissistic and self-absorbed they can only see their own situation. It's like non-mentalising - they can't mentalise the response of the victim, how that person would feel. That's another bad sign, because they're likely to be at high risk. So we try to assess - do they get it, are they genuinely remorseful, are they at high risk for recurrence. For some people we say we don't think it's a good idea even to go into a rehabilitation programme, and we suggest going into a different profession. It's very difficult to do with the person sitting there, but I've done it a number of times. Often they're expecting it.
Are you mandated to report where the person admits additional offences?
It goes in the report and generally the referrer will report it. There's a certain percentage of people who will break down - I look them in the eye and say 'are you really telling me the whole truth?’ - If you don't tell the truth this whole evaluation is a complete waste of time. Are you really being completely honest with me?’ And there's a percentage who get tearful and say 'Well there's another victim '. Now the hard-core narcissist may say 'Yes of course' but some will break down. Lie detector tests polygraphs are not admissible in open court. You could be making an error if you base it only on that. Polygraphs pick up a certain percentage. But you get false positives - the true psychopath has a low autonomic response so they can look you in the eye and say 'I didn't have sex with any child ever’ and there's no physiological response. The evangelists for polygraphs don’t' recognise that the true psychopath has a different autonomic nervous system.
I'm wondering what the places that run treatment programmes are treating, as a Boundary Violation is not a medical condition?
I think a lot of times it's denial. But you know I'm talking about three to five years of rehabilitation - a programme that goes on and is monitored for years. Usually there's no need for in-patient or residential. The programmes we set up are independent, to some degree, of disciplinary systems. Boards may get in touch and say 'We've suspended this person for 18 months, but we'd like you to see him and determine if it would be worthwhile to set up a treatment and rehabilitation programme.' So here's a typical programme - individual psychotherapy every week, with someone who knows boundaries; an educational seminar and restriction on practice, so if they're in solo practice they need to work in an institution or a group under supervision, and they have supervision on all their cases. We might say 'no patients with childhood trauma histories', restricting who they can see. Sometimes marital therapy, sometimes medication if they're very depressed. Those would be the major components. Then it needs to be monitored for three to five years. Before they can be outside the monitoring programme they need to be re-evaluated to see if they get it, if they have really benefitted from it. Many of them do. I think when they're carefully selected many of these people can be rehabilitated quite well.
Especially those who've had a lovesick situation where the infatuation wears off during the three to five years and they think 'I was acting irrationally, what was I thinking of; I love my wife, why did I do this?' so they get quite a bit better. Maybe half are rehabilitatable, that's an estimate but roughly what I would think. Someone who would never be recommended is the person who says 'I didn't do it'. I also say 'This isn't a courtroom, I'm not a private detective. I can't determine whether you did or didn't do it. I'm just a psychiatrist trying to evaluate whether you have any emotional problems. So I get out of trying to be judge and jury, or tricking them into saying anything. Most are admitting something by the time they get to me.
You have been very clear that often the issue is not black and white and that an understanding of the complexities of each case is vital. I am interested in whether ethically there are there some practitioners that simply shouldn't be rehabilitated?
Absolutely. There are severe narcissistic personalities and sociopathic therapists who are essentially predators who have no remorse for their transgressions. This is why a careful evaluation with substantial collateral information is needed to assess who can be rehabilitated and who cannot be rehabilitated.
What about long-term monitoring?
I learned the hard way that there has to be someone responsible for doing this. If it's up to the practitioner himself, nothing will happen. Church authorities may require that the clergyman take regular drug or alcohol screenings. An appointed rehabilitation coordinator will get a regular one line letter from the treating therapist which confirms that the person is attending treatment and thereby completing that part of the plan.
Victims
Sometimes the issue of Sexual Boundary Violation is taken as a kind of technical breach, an offence to good manners - could you give a perspective on the ethical basis for its proscription and something of what is established about harm to clients?
The essence of a fiduciary relationship where one pays another for a service is beneficence and non-maleficence. The relationship exists to help the patient and to avoid any harm. So sexual exploitation is a rip-off. One comes for therapy and instead receives sex. The problems that brought the person to therapy go unaddressed. Moreover, there is a power differential built in to the therapeutic relationship by virtue of one person paying another with a specific expertise. Hence it is a breach of power and a situation where one cannot give informed consent. There is ample evidence from clinical studies that patients feel harmed, betrayed, and may be refractory to subsequent treatment since they cannot trust future therapists. Some may not complain initially if they are in love with the therapist or marry the therapist, but that love is temporally unstable in most instances, and there is rage when the relationship goes sour. This is what Tom Gutheil and I call cessation trauma.
Could you expand on the ways in which non-sexual boundaries are breached, and the consequences of this for the patient?
There are many, many ways that nonsexual boundaries are breached. I will cite just a few: gossiping about a patient, making a business deal with a patient, soliciting a donation from a patient, asking a patient to babysit one's kids or work in the office, telling the patient you are in love with him/her. The patient is harmed because for therapy to work, it has to be clear that the patient is there only for treatment and for no other purpose. It is placing the therapist's needs before the patient's. Moreover, patients who are told ‘I love you’ or are treated as friends have false hopes raised that they will be something other than a patient for the therapist.
Do you see people who've been abused by practitioners?
Yes, as therapy patients. Sometimes a victim will come to me and want to make a complaint. Historically the victims have been neglected, not taken too seriously. One of the things I have done before is mediation, sitting down with the therapist. Getting the therapist to apologise can be tremendously important for the victim. And I've negotiated within mediation the therapist giving the client their fees back. Some of the practitioners feel they haven't done anything wrong so they don't want to apologise or explain. They can see the victim as responsible. I've had a mediation situation where the practitioner expressed his anger at the patient for ruining his career. It took several sessions for him to see that it wasn't just him who had been harmed. It turned out pretty good. He had to listen to the damage he'd done. They can be explosive sessions. Today I saw a woman who's a victim and she told me she never wanted to be in the same room as him again. Mediation is not right for everyone but it's good to have options available. She didn't want to make a complaint because of her feelings of ambivalence . She didn't want to ruin his reputation, destroy his family. So often people feel they have to make a decision, and friends are pushing them But they get paralysed and can't make a decision, so you have to give them time. So often the patient is permanently ruined in terms of therapy - they'll never trust anyone again. They say 'Why should I trust you, the last guy said he was trustworthy too.'
What about the rules governing former clients?
In another case the woman said to the male therapist 'Are you attracted to me?' and 'I know you're going to a meeting of the ... and I would like to meet you there, are you attracted to me?' and he said 'That would be highly unethical, for now this relationship has to be purely therapy'. She told me she hung on to those words 'for now' and she said that therapy stopped from that moment, because all she could think was 'for now'. That means ‘at some future point he may want me’. For the rest of her therapy she didn't talk about her problems - she tried to be an attractive enticing woman, so she wasn't doing therapy anymore, she was trying to seduce him. When there is a two year limit on sexual contact the therapy stops - the patient thinks 'I won't mention any sexual problems because he may not want to date me in two years, I'll keep quiet about all this.' I always make the point to my students that the reason the therapy works is that you are only a therapist for ever with this person. Once the patient understands that you will never be anything but a therapist, then they can really open up because there are no consequences in any other relationship. Once you depart from that you're in trouble. That's the reason why it makes sense to me to have an ethics code say 'once a patient always a patient' - there's no hope here for anything else so I might as well let it all hang out and tell everything about myself.
Risk Factors and Types of Transgressor
What is known about practitioners who violate boundaries?
A whole spectrum of different people do this for different reasons. I'm convinced that people hate complexity - they like to say 'all of these guys are bad, they're evil, they're predators, let's throw them out, throw the bad apple out of the barrel, then everything will be fine’. But it doesn't work that way. My students say: 'Why are you teaching us this Professor Gabbard, this is like, nothing I'm ever going to do, why will I ever need to know about this?' So yes, everybody’s vulnerable and people who think they'll never get in trouble are the people who may get in trouble because they're not thinking about it. Everyone of us is a master of self-deception. If you're working alone in a private office somewhere, without consultation, you can convince yourself 'I'm an exception. This isn't in any way exploitative, it's true love, there's nothing wrong with this'. So I teach that if you're going to be a therapist for the rest of your life you need a supervisor or consultant. You internalise them, you carry that person into the room with you and you're having a dialogue in your mind. That's the best prevention. Isolation, the solo practitioner working alone is a high risk, as there is a boundary problem built into that. You tend to drift away from what is accepted practice if you're totally by yourself.
Practitioners more advanced in their careers and often well respected are high risk. I have so many examples of that - the narcissistic guy who's well known in the field who says: 'Well you know the rules don't really apply to me anymore, because I know what I'm doing. If one of my supervisees did this I'd be worried about it, but I know what I'm doing, so I can get away with it'. It's crazy but that's one of the rationalisations. Or 'I'm unorthodox, people wouldn't understand. I couldn't talk to a supervisor because they wouldn't understand my approach - I've done it with lots of people and it's different but it works'. Narcissism, it's a huge problem.
Have you determined any differences between therapeutic modalities in terms of clinical profile or in how transgressions play out?
No, therapists of all persuasions are vulnerable. It has much more to do with the particular characteristics of the patient and therapist than any particular theory, technique or modality.
Are the majority of people that you see one time offenders?
Yes, but we see multiple offenders too. I'd say maybe 60% were one time.
How about those who are not the long-term predators of dozens of victims but may have 2, 4, 6 victims?
The narcissistically organised person. There are many narcissists who are generally womanisers, but haven't been doing it with patients. The guy who fancies himself a Don Juan, lots of girlfriends, several wives. But one patient, and that's why he gets sent to me. Then others who are quite superego ridden, very obsessive compulsive, do everything right, and they have a kind of mid-life crisis 'My God I've done everything by the book my whole life - I deserve one little transgression with one patient. For once I'm going to throw off the shackles of oppressive orthodoxy, I've earned it.'
Epidemiology, Regulation and Denial
The research into epidemiology of sexual boundary violations has some variation - what is your working view about how widespread an issue this is in the psychological therapies?
The simple answer is that we don't know the prevalence. There are questionnaire surveys but they all have notorious methodological problems. The return rate is low. Those who fill out the questionnaire may be different than those who don't complete the survey. Many do not trust the confidentiality of their responses since there is often a numerical coding involved. Some people don't tell the truth on questionnaire surveys. We certainly cannot rely on figures from ethics committees and licensing boards because they see only the tip of the iceberg. What I can say from over 30 years of evaluating and treating practitioners with boundary violations is that it is not rare.
You have led the way in enabling a conversation about boundary-less professionals to take place internationally, yet there remains significant and sometimes virulent denial of the extent of the problem in some quarters - do you have a view about why you think this is?
Sexual boundary violations are quite close to the incest situation symbolically. Someone in authority who should care about you and protect you instead exploits you for his/her own sexual pleasure. It taps something in all of us that is abhorrent, but unconsciously desired. There is a line in Sophocles’ Oedipus Rex, where the chorus, commenting on Oedipus says something to the effect of: ‘He did what most men only dream of.’ There is a huge tendency to project this vulnerability into a handful of psychopaths rather than to acknowledge the universal vulnerability, i.e. it is an occupational hazard for all of us.
One of the things I've noticed is that often when these boundary violations come out there's been knowledge in the practitioner community, but nobody really wanted to say. It's like they see it but they don't see it. One of the thing that goes on is, unconsciously, often the community of practitioners have a secret admiration for this guy who gets away with things. When President Clinton had that liaison with Monica Lewinsky his popularity went up in the polls. That makes it difficult sometimes to get information from the community because no-one wants to say anything. A lot of these practitioners, who are experienced, president of some organisation, respected, they often are good referral sources, they send patients to other people. They want to be loyal, they don't want to lose their referral source so they say nothing.
In the UK there is currently much debate about the statutory regulation of counsellors and psychotherapists. As someone who has been subject to statutory regulation for your whole professional career, have you ever felt that this impinged on your clinical practice, or your ability to innovate in the field?
No, I have never felt that. Any innovation that challenges statutory regulation must be scrutinized carefully because it is likely to contain problematic aspects that may get the practitioner into difficult situations with the patient.
Cultural Imperatives
Gabbard gives an example of a practitioner claiming that he had saved a patient from suicide by having sex with her. ‘They look you right in the eye and they believe it. It's not just a story, it's a rationalisation that they use to depart from their usual standards, and they think you've got a problem because you don't understand this. It's amazing. ‘Sometimes you have to do something unorthodox to save the patient...’ I've been interested in cinematic and TV depictions of psychotherapy. The audiences tend to love the kind of guy who’ll do something radical to save the patient. Then the Ethics Committee is a group of stuffy old men who say: 'You shouldn't be doing that'. You know there's a whole cultural influence to be that kind of maverick, who does his own thing. And that's seductive.’
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Gabbard Biography
Gabbard earned his Bachelor's Degree in Theatre from Eastern Illinois University and a M.D. from Rush Medical College in Chicago in 1975. He completed his psychiatry residency at the Karl Menninger School of Psychiatry in Topeka, Kansas. He then served on the staff of the Menninger Clinic for 26 years and served as Director of the Menninger Hospital from 1989 to 1994 and Director of the Topeka Institute for Psychoanalysis from 1996 to 2001. He moved to Baylor College of Medicine in 2001.
Gabbard has authored or edited 24 books and over 300 papers, including a book on media depictions of psychiatry and mental illness in films with his brother Krin. He was Joint Editor-in-Chief of the International Journal of Psychoanalysis and was Associate Editor of the American Journal of Psychiatry. Awards include the Strecker Award for outstanding psychiatrist under age 50 in 1994, the Sigourney Award for Outstanding Contributions to Psychoanalysis in 2000, the American Psychiatric Association Distinguished Service Award in 2002, the American Psychiatric Association Adolf Meyer Award in 2004, and the Rush Medical College Distinguished Alumnus in 2005.