False Accusations Against Therapists: Where Are They Coming From, Why Are They Escalating, When Will They Stop?

Lawrence E. Hedges^*

ABSTRACT: False allegations against therapists are discussed in terms of transference and countertransference issues.  Such allegations appear to come from clients with whom therapists believe they had a good relationship.  Most therapists, however, are unaware of the possibility of a hidden transference psychosis emerging and becoming directed at the therapist.  It is crucial for therapists to understand the dynamics underlying such false allegations.
  

Therapists At Risk

Over the past five years I have reviewed more than 40 psychotherapy cases in which serious accusations have been made by clients against their therapists.  Since, in most instances, the therapists sought consultation after the disaster had occurred, I could only empathize with them, offer some possible explanations for what had gone wrong, and wish them luck in their ongoing struggle to survive the damaging ravages of the accusation.

The majority of these therapists had already had their licenses revoked or suspended by the time I saw them and many had been through lengthy and costly litigation.  Others were dealing with losing their jobs and professional standing, as well as their homes and personal investments.  Malpractice insurance does not cover the enormous expenses involved in fighting an accusation at the level of a licensing board, a state administrative court, an ethics committee, or a civil case in which an allegation of sexual misconduct is involved.

Most of the therapists with whom I met were trying to understand what had happened to them.  Many had read In Praise of the Dual Relationship (Hedges, 1993), which discusses the emergence of the transference psychosis in which the client loses the ability to reliably tell the difference between the perpetrator of the infantile past and the present person of the treating therapist.  After the publication of that article, 22 therapists from five states traveled long distances with no other purpose than to simply tell me about the disastrous experience that had befallen them and to see if I could shed light on what had gone wrong.  Many accused therapists hoped that I would tell their stories to other therapists, advising them of the serious dangers currently facing us.  I recently described a series of these frightening vignettes in a book addressed to therapists on the subject of memories recovered in psychotherapy, Remembering, Repeating, and Working Through Childhood Trauma (Hedges, 1994b).
  

"It Can't Happen To Me"

My main business for many years has been working with therapists from many different orientations.  Much of my time is spent hearing difficult cases in which transference and countertransference problems have developed.  It is clear that most therapists are living in denial of the severe hazards that surround them in today's psychotherapy marketplace.  Often, when I have raised cautions regarding the potential dangers of a hidden psychotic reaction emerging and becoming directed at the therapist, I hear, "I'm not at all worried about this person suing me, we ve been at this a long time and we have a really good relationship."  This attitude is naive and dangerous.  No one knows how to predict the nature and course of an emergent psychotic reaction and no one can say with certainty that he or she will not be its target.

All of the therapists who told me about a disaster in their practice took great pains to tell me about the essentially good relationship they had succeeded in forming with the client.  Repeatedly I heard how, in the face of very trying circumstances, the therapist had gone the second mile with the client and had done unusual things in order to be helpful.  I frequently heard how a therapist had made special concessions because the client had "needed" this or that variation or accommodation "to stay in therapy."  In almost every case I heard that for perhaps the first time in this client's life, he or she had succeeded in forming a viable relationship with another human being, the therapist.  I was invariably told how, right at the moment of growing interpersonal contact or just when the relationship was really getting off the ground, "something happened" and "the client inexplicably turned against me."  Or, "an accidental outside influence intervened and the therapeutic relationship was destroyed," resulting in a serious accusation being hurled at the therapist.  Is there a pattern in these apparently false accusations of therapists? If so, what is it and how can we learn from it?
  

The Problem of Considering Accusations False

To speak of "false accusations" is to take a seemingly arbitrary point of view regarding an event that is happening between two people.  One person points the finger and says, "In your professional role of therapist I trusted you and you have misused that trust to exploit and damage me."  The accused may be able to acknowledge that such and such events occurred, but not agree on the meanings of those events or that exploitation or damage was involved.  If we had a neutral or objective way of observing the events in question and the alleged damaging results, we might indeed see a damaged person.  But would we be able to agree beyond a reasonable doubt that the observable damage is a direct causal result of exploitative acts by the accused?

In the type of allegation I am defining as "false accusation," it is not possible to establish a direct causal link between actions of the therapist and the damage sustained by the client.  Nor is it possible to establish beyond a reasonable doubt that the activities of the therapist in his or her professional role were exploitative.  In certain ways this definition may beg the question of what is to be counted as "false" when separate points of view are being considered.  But accusations as serious as professional misconduct carry a heavy burden of proof so that the question of true or false requires the establishment of a satisfactory standard of evidence — a standard which frequently seems to be lacking in accusations against therapists.  My position, drawn from impressionistic experience, is that there are many therapists who are currently being accused of damage they are not responsible for.  So what is the nature of the damage being pointed to and where did it come from?
  

Philosophical Bias or A Personal Blind Spot?

Many therapists, for a variety of reasons, have developed a personal or philosophical bias in their work against systematically considering the concepts of transference, resistance, and countertransference.  In choosing to disregard these complex traditional concerns and to embrace more easily grasped popular therapeutic notions, therapists may unwittingly be setting up their own demise.  All schools of psychotherapy acknowledge in one form or another the transfer of emotional relatedness issues from past experiences into present relationships.  Resistance to forming a living recognition of the influence and power of transference phenomena is also widely understood.  And countertransference reactions to the client and to the material of the therapy are universally recognized.  The personal choice involved in not noticing and studying what may be happening in these dimensions of therapeutic relatedness does not make them cease to exist.  It simply means that one is using personal denial or rationalization for keeping one's head buried in the sand and remaining oblivious to what dangers may be approaching as the relationship deepens.
  

The Broader Context: Memories of Abuse and Psychotherapy

The problem of false accusations made against psychotherapists is perhaps best understood when considered within the broader context of false accusations which arise from memories "recovered" in the course of psychotherapy.  Elsewhere I have written on the importance of taking recovered memories seriously and have reviewed a century of research and study on the problem (Hedges 1994b, 1994d).  Some key ideas will be included in the discussion which follows.

Recent shifts in public opinion have mandated changes in all sectors of our society aimed at correcting age-old patterns of abuse.  People who have been subjected to damaging treatment have felt encouraged to speak up and seek redress for the wrongs done to them in the past.  Memories of painful experiences which individuals have tried not to think about for many years are being revived and abusers are being confronted with the effects of their deeds.  This vanguard of the civil rights movement has generated public indignation and a call for more effective laws and judicial procedures to limit widespread abuses of all types.

But along with the revival of painful memories of abuse that people have done their best to forget, another phenomena has moved into the public arena — "recovered memories" which emerge in therapy with compelling emotional power but exist to tell a story that could not or did not occur in the exact or literal manner in which the abuse is so vividly remembered.  On the basis of such memories, usually recovered in some psychotherapy or recovery group setting, accusations on a large scale are aimed at people who claim not to be perpetrators of abuse.  As of August, 1994 the False Memory Syndrome Foundation in Philadelphia claimed more than 15,000 members claiming innocence for the crimes of which they are accused.

Highly respected public figures, as well as ordinary, credible private citizens known in their communities to lead basically decent lives, are having the finger of accusation pointed at them.  Among this group of otherwise credible people are numerous well-established individuals in the mental health field and other helping professions, including nurses, physicians, attorneys, the clergy; teachers, scout leaders, child care workers, and choir leaders — in short, all people in our society trusted in any way to care for others.  New laws in more than half the states have changed the statute of limitations to read, "three years from when the abuse is remembered," though it is not yet clear whether such laws will stand up in court.

By now accusations based on memories recovered in hypnosis, "truth serum interviews, recovery groups, and psychotherapy are coming under sharp criticism — partly because many of the accusations are so outlandish, partly because a sizable number of memories have proved to be faulty, and partly because of the "witch hunt" atmosphere surrounding the recovered memory controversy which threatens widespread injustice if responsible social controls are not forthcoming.

But accusations against therapists are usually carried out in confidential settings — administrative hearings, ethics committees, and civil cases which are confidentially settled — so that the process and the outcome of these accusations is still largely a matter of secrecy, with the result that therapists do not yet know where the danger is coming from or what its nature is.  A state and national grass roots movement has begun on a large scale which aims to bring into the light of day many miscarriages in justice for therapists.

There are clearly many issues to sort out in the recovered memory accusation crisis before we can regain our individual and collective sanity on this subject.  In Remembering, Repeating, and Working Through Childhood Trauma (Hedges, 1994b), I review the research on the phenomenon of memories recovered in therapy, concluding that if these memories are not taken seriously in the context in which they emerge, then we will indeed have a disaster on our hands.
  

Psychotic Anxieties and Recovered Memories

A large class of recovered memories can be related to primitive or "psychotic" anxieties which are operating to a greater or lesser extent in all people.  While we are now aware of much more real abuse than has ever been acknowledged before, this widely reported class of memories surfacing in psychotherapy today is not new.  Psychotherapy began more than a century ago based on the study of recovered memories of incest.  Clearly, the client has experienced some terrifying and traumatic intrusions — often in the earliest months of life, perhaps even without anyone really being aware that the infant was suffering subtle but devious forms of cumulative strain trauma.

Memories from this time period simply cannot be retained in pictures, words, and stories — rather the characterological emotional response system retains an imprint of the trauma.  Psychotherapy provides a place where words, pictures, and somatic experiences can be creatively generated and elaborated for the purpose of expressing in vivid metaphor aspects of early and otherwise unremembered trauma.

Psychoanalytic research since 1914 (Freud) has shown how "screen" and "telescoped" memories condense a variety of emotional concerns in a dream-like fashion.  "Narrative truth," which allows a myriad of emotional concerns to be creatively condensed into stories, images, somatic sensations, and cultural archetypes, has been well studied (Schafer, 1976; Spence, 1982) and understood to be the way people are able to present in comprehensible form memories from early life which could otherwise not be processed in therapy. All of these different types of constructed memories have been long familiar to psychoanalysts and serve as expressional metaphors for deep emotional concerns that are otherwise inexpressible.

Memories recovered during the course of psychotherapy need to be taken seriously — considered and dealt with in thoughtful and responsible ways by therapists, not simply believed in and acted upon.  A therapist who takes a simplified recovery approach of "remember the abuse, be validated by being believed, and then confront the abusers," is not only involved in a devious and destructive dual relationship but is actively colluding in resistance to the emergence of developmentally early transference experiencing and remembering with the therapist.
  

Transference Remembering

The most powerful and useful form of memory in bringing to light those primordial experiences is reexperiencing in the context of an intimate and emotionally significant relationship with the psychotherapist the traumatic patterns of the early experience.  I call the earliest level of transference experiencing with the psychotherapist the "organizing transference" (Hedges 1983, 1992, 1994a, 1994c, 1994d) because the traumas occurred during the period of life when infants are actively engaged in organizing or establishing physical and psychological channels and connections to their human environment.  Other psychoanalytic researchers speak of the "psychotic transference" or the "transference psychosis" which frequently appears in the therapy of people who are basically nonpsychotic.

Given the intensity of the primitive organizing or psychotic transference which is being brought to the psychotherapy situation for analysis and the actual dangers to the therapist which this kind of work entails, it is not difficult to understand: (1) Why many counselors and therapists without training or experience in transference and resistance analysis are eager to direct the intense sense of blame away from themselves and onto others in the client's past, (2) why so many therapeutic processes end abortively when transference rage and disillusionment emerge and psychotic anxieties are mobilized, and (3) how therapists can so easily become targets for transferentially-based accusations of abuse.  If personal responsibility for ongoing internal processes cannot be assumed by the client and worked through, then the blame becomes externalized onto figures of the past or onto the therapist of the present.  Continuing externalization of responsibility for feeling victimized and/or not adequately cared for is the hallmark of therapeutic failure.
  

Four Kinds of Remembering and "Forgetting"

Psychoanalysts and psychologists have no viable theory of forgetting, only a set of theories about how different classes of emotional events are remembered or barred from active memory.  "Forgetting impressions, scenes, or experiences nearly always reduces itself to shutting them off.  When the patient talks about these 'forgotten' things he seldom fails to add: As a matter of fact I've always known it; only I've never thought of it"' (Freud, 1914, p. 148).  Of course, there are many things around us which we do not notice and therefore do not recall.  Further, much of our life's experience is known but has never been thought about. Much of this "unthought known" (Bollas, 1987) can be represented in stories, pictures, and archetypes of the therapeutic dialogue and understood by two.  Even if sometimes a cigar is just a cigar," psychoanalytic study has never portrayed human psyche as anything so passive as to be subject to simple forgetting.  How then do analysts account for what appears to be "forgotten" experience?  Based on a consideration of the development of the human relatedness potential, psychoanalysts have evolved four viable ways to consider personality structure and to understand the different kinds of memories associated with each.
  

Four Developmentally Based Listening Perspectives

In order to discuss the nature of the primitive mental processes at work in false accusations we must establish a context by reviewing briefly the four developmental listening perspectives that have evolved in psychoanalysis for understanding four distinctly different types of transferences, resistances, and countertransferences (Hedges, 1983).  These listening perspectives are most often spoken of as four developmental levels, stages, or styles of personality organization, though we understand that every well-developed person may be listened to with all four perspectives at different moments in the therapeutic process.  In considering false accusations against therapists our attention will be drawn to the fourth or earliest developmental form of transference remembering.

1. In neurotic personality organization, the subjective sense of a five-year-old child's instinctual driveness is remembered in transference along with intense fears of experiencing sexual and aggressive impulses toward anyone so intimate as the analyst, because such intensity was forbidden in the family, social, or triangular structure.  At the level of neurotic personality organization secondary repression is brought about by self-instruction against socially undesirable, internal, instinctively driven thought and activity.  Note that the definition of repression does not include externally generated trauma but only applies to overwhelming stimulation arising from within the body.

2. In narcissistic personality organization, a three-year-old's intense needs for admiration, confirmation, and inspiration in relation to his or her parents or selfobjects are central to transference memories.  The natural narcissistic needs are enshrouded in shame regarding the desire to be at the center of the universe.  At the narcissistic level dissociation operates in which certain whole sectors of internal psychic experience are (defensively) walled off from conscious awareness in the main personality because they cannot be integrated into the overall span of the main personality.  Dissociated aspects of self experiences are not forgotten and are not considered unconscious.  Rather their presence in immediate action and consciousness is dependent upon the interpersonal situation present at the moment.

3. In borderline personality organization (four- to 24-month-old), transference remembering is rooted in the replication of a set of symbiotic or characterological emotional scenarios within the therapeutic relationship.  Resistance memories mitigate against living out the positively and negatively charged emotional interactions in the therapeutic relationship so that they can achieve representation and then be removed or relinquished.  At the symbiotic or borderline level, ego-affect splitting operates in which mutually contradictory affect states give rise to contrasting and often contradictory self and other transference and resistance memories which are present or not depending on the interpersonal context.  The split affect model of early memory used in understanding symbiotic or borderline personality organization postulates the presence in personality of mutually denied contradictory ego-affect states which represent specific transference paradigms based on internalized object relations (Kernberg, 1975).  Whether a split ego state is or is not present in consciousness is dependent upon the way the person experiences the current interpersonal relationship situation.  This means that what is remembered and the way it is recalled is highly dependent upon specific facilitating aspects of the relationship in which the memory is being recalled, expressed, or represented.  As such, transference and resistance memories represented in split ego-affect states are always complete and subject to distortions by virtue of the lack of integration into the overall personality structure.

4. In personalities living out the earliest organizing processes (from four months before to four months after birth), what is structured in transference memory is the rupturing or breaking of attempts to form sustained organizing channels to the other.  Resistance takes the form of terror and physical pain whenever sustained contact with a significant other threatens.  At the organizing developmental level, primary (neurologically conditioned) repression (Freud, 1895) acts to foreclose the possibility of reengaging in activities formerly experienced as overstimulating, traumatic, or physically painful. It is the organizing level of transferences, resistances, and countertransferences which usually give rise to false accusations.

Primary repression characteristic of the organizing period of human development is a somatic event based on avoidance of experiences which are perceived as potentially painful (Freud, 1895).  McDougall (1989) points out, "Since babies cannot use words with which to think, they respond to emotional pain only psychosomatically. ... The infant's earliest psychic structures are built around nonverbal 'signifiers' in the body's functions and the erogenous zones play a predominant role" (pp.9-10).  Her extensive psychoanalytic work with psychosomatic conditions shows how, through careful analysis of manifestations in transference and resistance, the early learned somatic signifiers can be brought from soma and represented in psyche through words, pictures, and stories.  McDougall illustrates how body memories can be expressed in the interpersonal languages of transference, and resistance, and countertransference.

Bioenergetic Analysis (Lowen, 1971, 1975, 1988) demonstrates the process of bringing somatically stored memories into the here and now of transference and resistance in the therapeutic relationship.  In bringing somatically stored memories out of the body and into psychic expression and/or representation, whether through psychoanalytic or bioenergetic technique, considerable physical pain is necessarily experienced.  The intense physical pain encountered is usually thought of as resulting from therapeutically "breaking through" long established aversive barriers to various kinds of physical experiencing which have previously proven frightening and were then forsaken.  That is, the threshold to more flexible somatic experience is guarded by painful sensations erected to prevent future venturing into places once experienced as painful by the infant or developing toddler.  The therapist who tells me, "these memories must be true because of the physical context" (i.e., vomiting, shaking, convulsing) seems not to realize that it is the physical manifestations which are the memory from infancy — not the images or stories which the client generates in order to metaphorically express or represent what that trauma was like to the infant self
  

Four Developmentally Determined Forms of Memory

Childhood memories recovered in the psychoanalytic situation fall into four general classes which correspond to the four types of personality organization just discussed:

1. Recollections of wishes and fears of Oedipal (triangular, four- to seven-year-old) relating which take the form of words, pictures and stories;

2. Realizations of self-to-selfobject (three-year-old) resonances which take the form of narcissistic (mirroring, twinning, and idealization) engagements with the therapist;

3. Representations of self and other (four- to twenty-four-month old) scenarios — in both passive and active interpersonal replications which take the form of actual replications of mutual emotional engagements with the therapist.

4. Expressions of the search for and the rupture of potential channels or links to others (four months before and after birth) which take the form of emotional connections and disconnections.¹  It is this last class of memories that interests us in considering the problem of false accusations against therapists.
  

The Rupture of Connections to the Other

The earliest transference and resistance memories are those from the "organizing" period of relatedness development (Hedges, 1983, 1992, 1994a, 1994b, 1994c, 1994d).  In utero and in the earliest months of life, the fetus and neonate have the task of organizing channels to the maternal body and mind for nurturance, evacuation, soothing, comfort, and stimulation.  Infant research (Tronick & Cohn, 1988) suggests that only about 30% of the time are the efforts made by an infant and mother successful in establishing that "rhythm of safety" (Tustin, 1986) required for two to feel satisfactorily connected.  The many ways in which an infant fails in securing the needed contact from its (m)other become internalized as transference to the failing mother. These disconnecting transference modes become enacted in the relationship with the therapist.

Because the biological being of the baby knows (just as every mammal knows) that if it cannot find the maternal body it will die, any serious impingement on the infant's sense of continuity of life, of "going on being" (Winnicott, 1965) will be experienced as traumatic.  An internalized terror response marks once failed channels of connection with a sign that reads, never reach this way again."  Such traumatic organizing-level transference memories are not only presymbolic, but preverbal and somatic.  Resistance to ever again reexperiencing such a traumatic, life threatening breakdown of linking possibilities is expressed in somatic terror and pain which mark "where mother once was and where I must not go again."

Winnicott (1965) points out that early impingements on the infant's sense of continuity with life oblige the infant to react to environmental failure before the infant is fully prepared to begin reacting and thinking.  The result of premature impingement is the formation of a primary persecutory mode of thought which forms the foundation of subsequent thought processes.  That is, traumatic impingement on the infantile (omnipotent) sense of "going on being," insures that the first memory which is destined to color all later memories is "the world persecutes me by intruding into my mental space and overstimulating (traumatizing) me.  I will forever be on guard for things coming at me which threaten to destroy my sense of being in control of what happens to me."

As a lasting imprint this earliest memory is essentially psychotic or unrealistic because the world at large offers many kinds of impingement.  And searching the environment tirelessly for the particular kind of primary emotional intrusion that once forced the infant to respond in a certain way not only creates perennial paranoid hazards where there may be none, but causes the person to miss other realistic dangers that are not being scanned for because of this prior preoccupation of the sensorium.  A person living out organizing states will do so without her or his usual sense of judgment, perception, or reality testing capabilities so that inner fears and preoccupations cannot be reliably distinguished from external features or forces.  Therefore, the person may be temporarily or perennially living in frames of mind that are, in essence, psychotic in nature though this may not be obvious to others.
  

Fear of Breakdown

Winnicott (1974) has shown that, when people in analysis speak seriously of a fear of a breakdown or a fear of death, they are projecting into future time what has already been experienced in the infantile past.  One can only truly fear what one knows about through experience.  Terrifying and often disabling fears of breakdown and death are distinct ways of remembering traumatic experiences that actually happened in a person's infancy.  What is dreaded and feared as a potentially calamitous future event is the necessity of experiencing through the memory of the evolving psychoanalytic transference the horrible, regressive, and once death-threatening breakdown the person experienced in a dependent state in infancy.

The fear of breakdown (from the infant's view) manifests itself in many forms as resistance to reexperiencing in transference the terror, helplessness, rage, dependency and loss of control once known in infancy.  Therapists and clients alike dread disorganizing breakdowns during the therapeutic process so that there are many ways in resistance and counterresistance that two can collude to forestall the curative experience of remembering by reliving the breakdown experience with the therapist.  One way for a therapist to collude with resistance to therapeutic progress is to focus on external perpetrators or long ago traumas to prevent having to live through deeply distressing, and frightening breakdown recreations together in the here and now therapeutic relationship.

The breakdown fear a person felt in infancy lives on as the somatic underpinning of all subsequent emotional relatedness but cannot be recalled because: (a) No memory of the experience per se is recorded — only a nameless dread of re-experiencing the dangers of infantile dependence and breakdown, (b) the memory of the breakdown experience itself is guarded with intense pain, somatic terror, and physical symptoms of all types, (c) the trauma occurred before it was possible to record pictures, words, or stories so it cannot be recalled in ordinary ways, but only as bodily terrors of approaching breakdown and death.  But massive breakdown of functioning is not the only kind of trauma known to occur in infancy.
  

Cumulative Strain Trauma

Masud Khan's 1963 concept of "cumulative trauma" adds a new set of possibilities to those already discussed.  Beginning with Freud's early studies of childhood trauma (1895), psychoanalysis has studied a series of possibilities regarding how the human organism handles overstimulation arising from the environment as well as from within the body.  As early as 1920 Freud envisioned the organism turning its receptors toward the environment and gradually developing a "protective shield":

"Protection against stimuli is an almost more important function for the living organism than reception of stimuli.  The protective shield is supplied with its own store of energy and must above all endeavor to preserve the special modes of transformation of energy operating in it against the effects threatened by the enormous energies at work in the external world" (Freud, 1920, p.17).

This protective shield later develops into consciousness, but even so remains somewhat ineffective in protecting from stimuli arising from within the body so that (secondary) repression finally evolves in the Oedipal age child.  But one way the infant organism attempts to protect itself from overwhelming internal stimuli is to project them into the outer environment and treat them as "though they were acting, not from the inside, but from the outside, so that it may be possible to bring the shield against stimuli into operation as a means of defense against them" (Freud, 1920, p. 17).  Thus, internally generated somatic or instinctual stimulation (both sexual and aggressive) are experienced as coming from the outside, from the other, rather than from ones own body.

The "false memory syndrome,) whether directed at perpetrators from the past or at the therapist in the present, appears to originate in earliest infancy (pre- or postnatal) when environmental stimuli cannot be effectively screened out, or when strong internal stimuli are projected to the exterior in an effort to screen them out.  In either case, due to the operation of primitive mental processes, the environment is "blamed" by the infant for causing stimulation that cannot be comfortably processed — though blame may be objectively inappropriate to the circumstances.

For example, one accuser's early problems were traced back to a "placenta abruptio," a detachment of the placenta from the uterine wall giving rise to a period of prenatal life without nourishment or evacuation.  Accusations may be traceable to shortages of oxygen in utero, to early problems in feeding, to infant allergies, to surgeries and medical procedures early in life, to incubators, to pain caused by accident or infection, to severely depressed mothers, to marital distress of the parents, or to an endless array of stressful early life events which were not deliberately cruel or abusive.  Khan observes that "... 'the strain trauma' and the screen memories or precocious early memories that the patients recount are derivatives of the partial breakdown of the protective shield function of the mother and an attempt to symbolize its effects (cf. Anna Freud, 1958)."

Kahn points out that the developing child can and does recover from breaches in the protective shield and can make creative use of them so as to arrive at a fairly healthy and effective normal functioning personality.  But the person with vulnerabilities left over from infantile cumulative strain trauma "nevertheless can in later life break down as a result of acute stress and crisis" (p. 56).  When there is a later breakdown and earlier cumulative strain trauma can be inferred, Khan is clear that the earlier disturbances of maternal care may have been neither gross nor acute at the time they occurred.  He cites infant research in which careful and detailed notes, recorded by well trained researchers failed to observe traumas which only retrospectively could be seen as producing this type of cumulative strain trauma.

Anna Freud (1958) has similarly described instances in which, "subtle harm is being inflicted on this child, and ... the consequences of it will become manifest at some future date."  Many symptoms and/or breakdowns in later life, occasioned by conditions of acute living stress, have their origins in infancy.  The adult experience of believing that one has suffered a vague, undefinable, and/or forgotten earlier trauma is attributable to the cumulative effects of strain in infancy caused by environmental failure to provide an effective stimulus barrier during the period of infantile dependency.  There may have been no way at the time of knowing what kinds of stimuli were causing undue strain on the infant because they were not gross and they were operating more or less silently and invisibly.  Or the circumstance may have been beyond the parent's capacity to shield, as in the case of medical problems, constitutional problems, or uncontrollable environmental problems, e.g., war, food shortages, concentration camps, family discord, etc.  But the key consideration for our present topic is that when a person in later years, under conditions of living stress, produces memories of the effects of the cumulative strain trauma, what is remembered is abstracted, condensed, displaced, symbolized, and represented visually in screen memories which operate like dreams so that an accurate picture of objective facts is, in principle, forever impossible to obtain from recovered memories.

In expressions of searching for and breaking off (primary repression of) the possibility of contact with others, the early traumatic ways the nurturing other ruptured or failed to sustain contact live on as transference and resistance memories which interfere with subsequent attempts to make human contact which would lead toward full emotional bonding.  Organizing (or psychotic) transference memory involves the search for connection versus a compulsion towards discontinuity, disjunction, and rupture of connections.  The resistance memory exists as the person's automatic or inadvertent reluctance to establish and/or to sustain consistent and reliable connection to the other (which might serve to make interpersonal bonding of these somatic experiences a realistic possibility).
  

Illustrations

Case Illustration: Switching Personalities

It is this organizing experience and the reluctance to permit or to sustain, here and now connectedness experience, that I and my clinical colleagues have researched and written about extensively.  A brief example of what an organizing level transference disconnect might look like in a clinical situation suggests a direction for consideration.

A therapist working with a multiple personality presents her work to a consultant.  After an overview of the case is given, the consultant asks for the therapist to present "process notes" (event by event) of the next session for review.  The therapist begins reading the process notes, telling how her client, Victor, began the hour and how the client gradually zeroed in on a particular emotional issue.  The therapist hears the concerns and very skillfully empathizes with the client's thoughts and feelings.  Suddenly "little Victoria, age 4" appears in the room.  The "switch" is significant in all regards and the therapist now listens to what the alter, Victoria, has to say.  The consultant asks how the therapist understands what has just happened.  The answer is that Victor felt very understood in the prior transaction and in the safety of the presence of the understanding therapist a more regressed alter (Victoria) can now appear.  This kind of event is ubiquitous in the treatment of organizing experiences — an empathic connection is achieved by the therapist and there is a seemingly smooth and comfortable shift to another topic, to a flashback memory, or to an alter personality.  The therapist had to work hard to achieve this connection and feels gratified that her interpretive work has been successful.  The therapist feels a warm glow of narcissistic pleasure which is immediately reinforced by the client's ability to move on to the next concern.  Wrong!

When organizing or psychotic issues are brought for analysis, what is most feared on the basis of transference and resistance is an empathic interpersonal connection.  This is because in the infantile situation the contact with the (m)other was terrifying in some regard.  A more viable way of seeing the interaction just cited is to realize that the successful empathic connection was immediately, smoothly, and almost without notice ruptured with the shift!

The therapist may fail to see what happened for perhaps several reasons: (a) The therapist is a well-bonded person and assumes unwittingly that empathic connection is experienced as good by everyone; (b) the therapist doesn't understand how organizing transference and resistance operate and so is narcissistically pleased by the apparent connection he or she has achieved; (c) the client is a lifetime master at smoothly and efficiently dodging interpersonal connections — across the board or only at certain times when organizing issues are in focus; (d) a subtle mutual seduction is operating in the name of "recovery" in which resistance and counterresistance are winning the day with both parties afraid of personal and intimate connectedness presumably because of its intense emotional demands; (e) the personality switch, sudden flashback, or change of subject focuses both on the historical causes of the dissociation o~ some other red herring; or (f) the search for memories and validation forecloses the possibility of here and now transference experiencing of the emotional horror of infantile trauma and breakdown and how the connection with the therapist is stimulating its appearance. In all of these possibilities the tragedy is that the very real possibility of bringing to life and putting to rest traumatic memory is lost by the therapeutic technique being employed.
  

Case Illustration: Marge

In Remembering, Repeating, and Working Through Childhood Trauma (Hedges, 1994b) I report a series of vignettes brought to me by therapists in trouble.  The following is reported by a male therapist with 14 years of experience (pp.288-292).

"I saw Marge for two and a half years.  She came to me after her children were grown and left home.  She was a chronically depressed housewife in danger of alcoholism.  A psychiatrist prescribed medication for her but she kept going downhill.  Nothing I could do or say seemed to help.  She didn't want to go to work or school to bolster her skills.  She belonged to church which was group enough for her.  She worried if her husband were having affairs on his sometimes week long business trips.  She mostly stayed home, watched television, ate, and slept.

"On the day that later came into question Marge was more depressed and despairing than I had ever seen her.  Many times she had spoken of having nothing to live for, and of being despairing because no one cared about her and life was meaningless.  The few friends she had she couldn't talk with.  Marge said she was ready to end it all.  Inside myself during the entire session I had to continually assess the seriousness of the suicide threat.  It seemed serious.  I could see that today I was going to have to obtain a contract for her to call me before she did anything to hurt herself.  But could I trust her even that far?  Was I going to have to call the paramedics or police before I let her leave?  I tried everything I could think of but could achieve no connection.

"Marge had sat on the end of the couch further away from me than usual today.  With ten minutes left I asked her if I could sit on the couch near her for a few minutes, thinking that perhaps that might help.  She assented with some faint signs of life.  A few minutes later, in desperation I asked if it would help her feel more safe if I put my hand lightly on her shoulder.  She thought she might like that and shortly perked up enough for me to let her leave safely.  Now, Dr. Hedges, I have four children.  I know what a father's reassuring hand can mean and what it feels like — and I swear to God that's the way it was.  I also believe that was the way she received it at the time because we seemed to connect and she took heart.  We continued therapy some months and Marge began to get better, to relate to people more, and to take night classes.  It seemed like some sort of turning point in our relationship, like we had passed through a crisis together.

"To make a long story short, her husband lost his job, her insurance ran out, and I drastically cut my fee so we could continue meeting.  After some months she was doing much better and the financial situation was getting even worse so she decided to take a break from seeing me, but the door was left open for her to continue her therapy at a subsequent date if she chose.  Several years later I closed my practice entirely and left the clinic where I had been seeing Marge to take a full time job for a managed care company.  She wanted to be seen again and found how to contact me.  I explained to Marge over the phone the reasons why I could not continue working with her — at that point I had no office, no malpractice insurance, no professional setup in which I could see her.  She was enraged.  I had always 'promised to love her and to see her no matter what,' she claimed.  She wrote a threatening letter to the director of the clinic where I had previously seen her.  He asked if we three could meet together.  She was insinuating I had behaved inappropriately with her, had hugged and kissed her and made all manner of promises to her — none of which was true.  All of it was apparently fabricated from that one incident and her sense of my ongoing commitment while working with her.  This meeting with the clinic director settled her down a bit and she recanted the things she had said in the letter.  He tried to arrange for her to see another therapist which she refused to do.

"Shortly thereafter Marge caught her husband in what she was sure was a lie about some woman he was involved with at work.  Again she demanded to see me.  I spoke with her on the phone, and again tried to assuage her rage that I could not see her.  She was in a tirade of how I was abusing her.  By this time she had been in an incest survivors group for a while and she had gained plenty of validations for her rage at her abusive parents and so was much freer to rage at me.  I supported her anger and I gave her appropriate referrals.

"The next thing I know an armed investigator from the state licensing board shows up at my work with an attache case and a lot of questions.  Marge had written a letter alleging sexual misconduct.  I was not allowed to see the letter of accusation.  You know we have no civil rights in administrative proceedings.  When accused we are presumed guilty until proven innocent.  But I did discover that she accused me of making love to her on my couch for a whole hour, promising her unending love and devotion, and then that I had made her promise not to tell.  The 'promise not to tell' part clearly linked her current delusional accusation to her childhood molestation.

"Whatever Marge told the licensing board, my attorney tells me I am in deep trouble because I'll never be able to prove it didn't happen.  I have some notes, but ten years ago we didn't keep many notes so I don't know what good they will do.  And anyway I don't keep notes on things that don't happen.  I'm told I may lose my license to practice psychotherapy.  And if she wins at this level there's malpractice settlement money waiting for her to go after.  I'm really worried.  I have a good job and a family to support.  If charges of sexual misconduct are made I could lose my job and everything I own trying to defend myself.

"We were doing good work and we both knew it.  We got to many of the really terrible things that happened to her in childhood.  I had her on her feet and moving in the world again and I think I could have gotten her out of her deep and life-long depression and low self-esteem if the insurance money hadn't run out.  And now this.

"I came to see you because when I read your paper, 'In Praise of the Dual Relationship,' and I got to the part about the psychotic transference I suddenly saw what had happened.  You said something to the effect that the tragedy is that the therapy has succeeded in mobilizing deep psychotic anxieties in the transference.  But that then reality testing becomes lost and the therapist is confused in transference with the perpetrator of the past.  That really happened.  We were never taught about such things in school.  Do you have any ideas about how I can get myself out of this jam?"
  

Commentary

The most disruptive and dangerous thing a therapist can do when working with an organizing transference is to successfully connect to the person without adequate working through of the resistance to the emotional connection.  Yes, this man saved the day and didn't have to hospitalize his patient.  He succeeded in calling her back from the brink.  But he is deluded in thinking that connection is experienced as good by people living organizing experience.  I think she never forgave him for approaching and connecting when she wanted distance.  And then he became fused into her psychotic fantasies as yet another perpetrator.  Her distress that she can not have him further fuses him to the image of the neglectful, tantalizing, or teasing perpetrator.

Also, physical touching for the purpose of providing comfort or reassurance is never a good practice.  If it's not misunderstood as a seductive invitation it will surely be seen as a replication of an abusive penetration.  I do see one certain, carefully defined potential use for interpretive touching in work with organizing or psychotic transferences.  But interpretive touch is a carefully calculated concretized communication given at a critical and anticipated point in time when the person is having a hard time sustaining a connection and clearly understands the communication (Hedges, 1994c).

The problem which the licensing board will have no way of understanding is that the therapy was going well until outside forces interrupted, plunging Marge into despair with which her therapist successfully connected.  The psychotic transference then operated to fuse his contact with contact in childhood which was traumatic.
  

Therapists At Risk

I hope I have succeeded in drawing attention to how precarious our current situation is.  We have learned how to follow people deep into their infantile psychotic anxieties in order to provide an opportunity for reliving and therapeutic mastery of the problem of emotional contact in the context of an adult psychotherapy relationship.  But the possibility of a negative therapeutic reaction looms large.

In Working the Organizing Experience (Hedges, 1994c), I specify a series of features that characterize the development of the transference psychosis, elaborate on common subjective concerns of the person living an organizing experience, and provide a series of technical issues to be considered by therapists choosing to do long-term, intensive psychotherapy.  The companion casebook, In Search of the Lost Mother of lnfancy (Hedges 1994a), provides a theoretical and technical overview of working the organizing experience as well as lengthy and difficult in-depth case study reports of long term work with organizing transferences reported by eight psychotherapists.  The working through of the organizing transference or transference psychosis is demonstrated when it exists as the pervasive mode of the personality as well as when it exists only in subtle pockets of otherwise well developed personalities.

Clients who were traumatized early in life are at risk for the development of a negative therapeutic reaction in the form of a transference psychosis that can be suddenly, surprisingly, and destructively aimed at the person of the therapist.  False accusations against therapists will not stop until therapists become knowledgeable about how to work with the primitive processes of the human mind.
  

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