Helen Bramson: Treatment After Sexual Abuse by a Mental Health Practitioner
Janet W. Wohlberg and
Elizabeth Aub Reid
Patients who have had sexual contact or sexualized relationships with previous therapists present a unique set of subsequent treatment complexities. From the patient’s perspective, the breach of trust experienced in the previous therapy has likely made the formation of a new therapeutic alliance both threatening and compelling. It is likely also that whatever caused the patient to enter therapy in the first place has never been treated.
Based on anecdotal evidence from the more than 600 participants of the Boston-based support network, TELL (Therapy Exploitation Link Line), and contacts with victim/survivors throughout the English-speaking world, it appears that the modal patient in this population has developed heightened sensitivity to rejection and issues of safety. This patient often continues to shoulder blame for what took place, may be confused about what appropriate boundaries should be, and is likely to be ambivalent toward the previous therapist. Victim/survivors commonly report “therapist shopping,” i.e., seeing as many as 15 to 20 subsequent therapists before finally settling down. One “false step” by the potential subsequent treater, such as vilifying the former therapist, pushing the patient to take action, or suggesting that the events of the former therapy are not of primary importance or concern, will likely send the patient out the door, never to return.
While a position of “neutrality” towards the events of the abusive therapy may sustain the subsequent treatment for a number of sessions, almost inevitably the patient leaves to seek a therapist who expresses clarity around what took place and who carefully delineates safe subsequent treatment boundaries. Victim/survivors are most likely to settle into a therapy in which the subsequent treater states that what took place was wrong, that it is always the responsibility of the therapist, and that it is an important therapy issue.
Like patients, subsequent treaters also face problems with the breach of trustperhaps by a trusted colleague and with ambivalence towards the abusive treater. A well-known Boston psychiatrist was horrified to learn that a good friend in another state, to whom she had referred numerous patients over the years, had lost his license for having had sexual relationships with several female patients. After stating how furious she was with him, she went on to ask two poignant and telling questions, “Should I call the people I referred to him to ask if everything is all right?” and “Is it okay to still like him as a person?” White (1995) details six models that describe traditional reactions by the professional community to revelations of sexual exploitation of a patient by a colleague: These include marginalization of the professional, vilification of the patient, and minimization of the importance of the events. One or more of these reactions is likely to be present in the subsequent treater, creating serious counter-transference issues.
The following case, written collaboratively by a psychiatrist and a victim/survivor of sexual abuse by a psychiatrist, is an amalgam of incidents from actual cases, blended to avoid problems of confidentiality. It raises issues about the damage that sexual contact between therapist and client is likely to produce, about the powerful feelings such patients’ experiences call forth in therapists, and about how these make subsequent treatment particular and difficult. The brief discussions that follow each case section are meant to raise only some of the central issues and are by no means comprehensive.
Helen BramsonPart A
It was early October when Dr. Lee Wright* received a call from Helen Bramson who requested an appointment “as soon as possible.” She said she had been referred by a colleague of Dr. Wright, Dr. Charles Baker, who had earlier told Dr. Wright to expect the call and that the patient had experienced some problems in a previous therapy. Beyond this, Charles had known very little except that Ms. Bramson was distraught, needed to be seen quickly, and that the reason for the current distress was unclear. Charles did not have time available to see her himself.
The patient agreed to be seen at Dr. Wright’s earliest available hour, even though it proved to be a difficult time for her. Knowing that finding the entrance to the office, though obvious once there, could be a little tricky, Dr. Wright had given Helen meticulous and detailed directions.
On the day of the appointment, Helen Bramson showed up five minutes late, explaining that she had gotten confused and had wandered around before she was able to locate the office. From prior experience, Dr. Wright associated this behavior with a high level of anxiety.
Helen, who looked to be about 5’2” and 130 pounds, was neatly dressed in navy slacks, a white blouse, and a plaid blazer. Her hair was straight and blunt-cut just below her jaw line. She wore little jewelry and little make-up and had what struck Dr. Wright as a somewhat nondescript face. She said she was 33 years old, had a masters in counseling psychology, and was married to a lawyer.
During the session, Helen fidgeted almost constantly, variously pulling at her fingers, smoothing her pants, pushing her hair away from her face, and shifting in her seat. In addition, she seemed to have a hard time looking at Dr. Wright and carefully avoided eye contact. She spoke fast and in a soft voice that was, at times, barely audible, but she also seemed to become anxious and a little angry when asked to repeat something that Dr. Wright hadn’t heard clearly. All of this, as well as other parts of her story, were in contrast to her statements that she had a stable marriage, a highly challenging and fulfilling job, and two children who she said were doing well socially and in school.
After taking an initial history, Dr. Wright carefully outlined what the patient could expect during this session and beyond. Dr. Wright also explained that this was to be only the first in a series of no fewer than two and probably no more than five evaluative sessions, after which Dr. Wright would let Helen know if and how they might proceed. Dr. Wright then asked Helen to describe just what it was that brought her into this consultation.
Helen seemed to have a difficult time focusing, and her story was quite hard to follow. She said she felt very anxious, was sleeping poorly, and couldn’t concentrate. “I also can’t seem to control my temper,” she said, “and feel like sometimes I get angry at nothing. I just lose it with my kids and my husband.” Helen went on to describe the tension that was building at home because of her behavior, said that she was easily startled, and explained that she found herself constantly thinking about what had happened to her in her previous therapy. It was this last piece of information that Dr. Wright decided to pursue.
“Why don’t you tell me a little more about what it was that happened in that therapy?” Dr. Wright suggested.
“I had an affair with him,” Helen began, quickly becoming weepy, “and we were going to get engaged or something just as soon as he could break it to his wife that he wanted to leave her. I don’t think I really ever imagined myself married to him. He said he really loved me, and I really loved him and tried to help. He has had such an awful life, and I know he really needed me. His first wife died of breast cancer, and his wife now is a real shrew. She just spends his money, doesn’t cook or do any laundry. He told me she’s really cold and that they rarely ever have sex.”
Dr. Wright consciously checked an impulse both to express feelings at this revelation and to try to figure out who the therapist might be, in order to better focus on Helen’s story.
“Sometimes in sessions,” Helen went on, “he would bring a bottle of wine -- ‘just to relax us,’ he said, and make it easier for us to talk. I felt so sad for him. After awhile, he switched my appointment to the last one of the day so we could have more time together. He never charged me for the extra time. Sometimes I even stayed late to help him with his bills and type up his patient notes. He had had a part-time secretary, but that was expensive, and I wanted to help him. With his wife spending so much money, he just couldn’t afford to keep paying a secretary. He was in so much pain.”
“He’s really brilliant. A couple of times I typed up papers that he was going to give at conferences. He’s famous, you know, and other therapists were always calling him while I was thereto ask him questions. We spent a lot of time talking about some of his patients, and he asked me for my advice on what to do in a couple of cases. He told me he thought I had wonderful clinical judgment, and he even referred two clients to me.”
“When I first went to see him, I was pretty uncomfortable that he asked me so much about sex. I meanthat’s something we don’t talk about very much in my family. I was a virgin when I got marriedhe seemed pretty interested in that, and we talked a lot about it. We probably talked more about that than anything elsesex, that is. Anyway, he told me his first wife was a virgin when they got married, too.”
“When we first started getting closeI had been seeing him for about eight months,” Helen continued, “I was pretty scared. At first I didn’t think I was particularly attracted to him, and it wasn’t until he asked me what sexual fantasies I was having about him that the dreams started. I guess that until that time I had just been denying my real feelings.”
“When I told him about my dreams, he told me he had fantasies about me, too, and he described them in pretty graphic detail. I was surprised because I’ve never really considered myself to be someone who, you know, turns men on.”
“One day I came to a session upset because I had had an argument with my husband. He put his arm around me and held me and kissed me. It was really confusing. I really love my husband and had never thought about having an affair. But he told me that part of my problem was that I had never experienced sex with anyone other than my husband and that our having a physical relationship would help me. At first it was mostly just kissing and touching, but after a few weeks we began to take our clothes off, and eventually we had sex. Well, we never had regular sex. Mostly I would take care of him with my hand or we’d have oral sex.”
“After almost two years, I told him that I needed to see someone else. I felt so guilty, and things weren’t going so well with my husband. I hated lying to him, and I was still trying to figure out whether or not to move ahead with my training and just what I wanted to do with my life. I didn’t want to tell him that I had already started to see Dr. HenniganPhilip Hennigan, you might know him...?”
Dr. Wright gave a vague, noncommittal shrug, trying not to let on that they had trained together and continued to be both friends and colleagues.
“Anyway,” Helen went on, “even though he didn’t know about Dr. Hennigan, he got really mad at me and said that if I insisted on seeing someone else, he wouldn’t be able to see me anymore. About three days later, he called and left a message on my answering machine not to come back. He wouldn’t return any of my phone calls or answer my letters. I even tried sending a telegram, but he wouldn’t accept it. I don’t understand what I did.”
“I was so upset after it ended that I guess I really went off the deep end. Dr. Hennigan was really helpful for a while. When I lost my job and things got really bad at home, I seriously considered killing myself. I actually took a bunch of pills, but I guess I wasn’t really serious because I only ended up throwing up a lot and then sleeping.”
“Anyway, I was under a lot of pressure, and Dr. Hennigan agreed to just collect from my insurance and let me pay the rest when I was able. It took me about six months to get another job, but then Dr. Hennigan started pushing me to pay what I owed him. I really didn’t have the money, and he just kept insisting that I had to pay. It was a lot of money, and I didn’t have it.”
“And then he went on vacation. He claimed he told me a bunch of times that he was going and when. I don’t think he reminded me that he was going at all, so when I went for my usual appointment, he wasn’t there. He says he told me, but all he really did was mention he might be going about two months before he left.”
“I finally got so pissed, I quit. That was almost a year ago. What he did to me wasn’t fair, and I think it was pretty unethical. I talked to a friend who’s a lawyer, and I might just report him to the psychiatric association’s ethics committee. He’s slime. I ....”
Dr. Wright interrupted Helen. “So what brings you into therapy now?”
“I haven’t been sleeping too well, and sometimes I feel kind of anxious, but I’m not sure why. Mostly, I just want to figure out what to do about my career. My mother never worked, so I’ve really never had much of a role model, and when she died last year, well, I’m not sure I ever really worked out my feelings about that.”
Discussion: Part A
Helen’s story reflects several frequent themes of patients who have been sexually involved with former therapists, including: idealizing the therapist; being privy to extensive personal information about the therapist, particularly information that suggests the need for the patient to take care of the therapist, including sexually; doing personal chores for the therapist; feeling suicidal; feeling guilty; and experiencing an inability to control and direct anger.
Although Helen expresses no anger toward the abusing therapist and says she is fearful of her tendency to take out her anger on her family, she appears to feel safe and justified in her fury at Dr. Hennigan. Victim/survivors frequently project anger at their abusers onto subsequent therapists, making treatment stormy. The ability of the patient to feel anger may signal a readiness to deal with the issues of the abusive therapy; a central goal of subsequent treatment should be to help the patient appropriately direct that anger.
Helen appears to take responsibility for the relationship with her abuser, telling Dr. Wright, “I had an affair with him.” A crucial first step in healing for victim/survivors is coming to accept that what took place was not an affair, that “affair” implies mutuality of interest and responsibility, and that it is the therapist’s responsibility to see to it that sexual feelings are not acted out in the therapy. Self-help groups and group therapies in which patients are able to meet other victim/survivors who are at various stages of the healing process are especially effective in helping victim/survivors change their nomenclature and begin the painful process of reinterpreting what took place.
Dr. Wright starts off carefully, detailing the boundaries of the proposed evaluative sessions, making clear what will and will not take place, and picking up on Helen’s comment about the former therapy. The decision not to press for the name of the former therapist gives Helen an opportunity to protect the object of her ambivalence as long as necessary. When Dr. Wright, apparently out of anxiety, stops Helen’s tirade against Dr. Hennigan to ask, “So what brings you into therapy now?” Helen obligingly shifts directions to safer territory, i.e., career and loss of her mother. Consciously or unconsciously, Helen has been sent and has received the message that her relationship with Dr. Hennigan is not a topic for this therapy. If Helen’s anger towards Dr. Hennigan is projected from the abusive relationship, it is quite possible that Helen will see that relationship as off limits for this therapy as well.
Helen Bramson - Part B
Dr. Wright realized that the personal sense of outrage aroused by Helen’s story was making it increasingly difficult to listen to her. Added to this was some real concern about Dr. Hennigan and whether or not they should have a “colleague-to-colleague” chat about this patient’s accusations. Dr. Wright was aware that it was hard to feel empathy for Helen where Phil Hennigan was concerned. Phil was a real friend and would never knowingly hurt a patient or do anything unethical; but perhaps it was possible that Phil had extended himself a bit too far with this patient and, without realizing it, had asked for trouble. Still, he was clearly nothing like this other so-called “therapist” whose behavior was so obviously professionally improper and ethically outrageous.
Wrestling with whether or not to make this sense of fury and pain at an abusive colleague known to Helen, remain passive and untouched, or wait for Helen to say more, Dr. Wright finally decided it would be best to find out what Helen wanted to do and whether or not she had considered her options.
“Have you consulted a lawyer?” Dr. Wright asked.
“About Dr. Hennigan? I told you I already spoke to someone.”
“No, about the other one.”
Helen seemed startled. “Why?”
“Well, what he did was unethical, and you should consider suing. I could give you the name of someone. Of course, if you want to do that, I can’t be much help. I’m not going to testify in court, so if that’s what you want, maybe you should see someone else. I don’t want anything to do with going to court, but you could sue.”
“I can’t do that. I don’t want to do that.”
“Well, you should at least report him to his professional organization or to the licensing board. After all, you have a responsibility here.”
“But I don’t want to do that either.”
“Well, let me explain to you what would be involved in reporting him to the licensing board. You’d go down to their officeit’s right down townI could make the initial contact for you and help you set up an appointmentand tell them what happened. There might be others who have already complained. It’s possible that I’ve even heard of him doing this to other people. Who is he?”
“Dr. Hennigan,” Helen responded with an edge of annoyance in her voice.
“No.” This time it was Dr. Wright’s voice that betrayed some vexation. “The other therapist.”
“I can’t tell you. He said if I ever told anyone about us it would really hurt him. And, besides, if he found out, he’d be really angry. He has a lot of powerful friends.”
“Look, Helen,” Dr. Wright said insistently, “if we’re going to work together, you’re going to have to trust me. You really should tell me who he is.”
“But I really don’t need to talk about him. He isn’t the issue. I’ve worked all that through. I came here for therapy. I need to make some decisions about what to do with my life.”
“All right,” Dr. Wright said reassuringly, “but our time for today is up. Let’s set another appointment for next week.”
Dr. Wright and Helen found a time convenient for both of them for the following week, and Dr. Wright assured Helen that if she needed to talk in the meantime, she was welcome to call on Monday, Wednesday, or Friday nights between 8 and 9:45.
With that, Helen got up and left.
Discussion: Part B
After telling Helen that what took place in the abusive therapy was unethical, Dr. Wright then strays into dangerous territory by failing to recognize Helen’s ambivalence. Even when Helen makes clear both her sense of needing to protect the abusive therapist, “…it would really hurt him,” and her fear, “…he’d be really angry. He has a lot of powerful friends,” Dr. Wright continues to press. Dr. Wright appears to recognize, but seems unable to control, the counter-transference problems that Helen is stimulating. Ultimately, Dr. Wright makes at least two of the critical errors that victim/survivors report most often lead to their decisions not to continue with a therapist: First, Dr. Wright insists “you’re going to have to trust me.” This is equivalent to the proverbial waving a red flag in front of a bull. Overwhelmingly, victim/survivors report their abusers insisting on unquestioning trust. In fact, there is every reason for the patient to mistrust the new therapist, and the suggestion that trust is critical to the therapy may lead the patient to ask, “then what’s the use?”
Second, Dr. Wright draws unwarranted conclusions as to what Helen’s action options are. Victim/survivors, while needing to be fully informed as to the options (Milgrom), may eventually elect to do nothing, or may choose multiple approaches, legal action being but one. Dr. Wright also sends a mixed message: “You should take action, but I’m not going to help.” In examining the counter-transference, it will be important to consider to what degree Helen is being asked to fulfill Dr. Wright’s apparent need to take action. Conversely, Dr. Wright is correct in not wanting to take on the dual role of therapist and advocate, a role that could easily compromise the therapeutic alliance.
Helen BramsonPart C
What Dr. Wright did Wrong
After Helen left, Dr. Wright spent some time thinking about what had taken place and particularly about how the anger, pain, and frustration experienced by both of them had intruded on Dr. Wright’s ability to listen openly. Dr. Wright had certainly been aware of these feelings and problems during the session, including the protective feelings towards Dr. Hennigan and the outrage towards the abuser, and had seriously attempted to put these feelings aside. But this, of course, was not possible.
Upon further reflection, Dr. Wright also realized that it would have been far better to have acknowledged that Helen might not have been immediately clear on why she had come and what her expectations were, and that was okay. Dr. Wright also recognized that probing Helen to reveal details of the abusive relationship and the abuser’s name was due to counter-transference and had resulted in a failure to recognize ambivalence on the parts of both therapist and patient. The same was true of Dr. Wright’s digression into process issues and away from feelings. Additionally, having been once so betrayed by a therapist, it was unrealistic to believe that Helen could so easily trust again.
On the following Saturday evening, Helen Bramson left a message on Dr. Wright’s answering machine canceling her appointment and saying she would call back if she wished to reschedule. That was the last time Dr. Wright heard from her.
Discussion: Part C
It’s not surprising that Helen elects to call Dr. Wright to cancel her appointment when she knows she will get only an answering machine. Dr. Wright may wish to call Helen, acknowledge that there are serious potential problems with Dr. Wright undertaking Helen’s case, and offer to refer her to someone who might be able to be more neutral. Keep in mind, however, that even had Dr. Wright done everything right, Helen may still have fled, not yet ready or able to confront the issues raised by the abusive treatment.
Milgrom, J.H. (1989) “Advocacy: Assisting Sexually Exploited Clients Through the Complaint Process” in Schoener, et al (1989) Psychotherapists’ Sexual Involvement with Clients: Intervention and Prevention (Walk-In Counseling Center: Minneapolis) pp. 305-312.
White, W.L. (1995) “A Systems Perspective on Sexual Exploitation of Clients by Professional Helpers” in Gonsiorek, J.C., ed. (1995) Breach of trust: Sexual Exploitation by Health Care Professionals and Clergy (Sage Publications: Thousand Oaks) pp. 176-192.
* Authors’ note: Dr. Lee Wright is presented as a gender-neutral character, as both male and female subsequent treaters appear to struggle with many of the same counter-transference issues.
Janet W. Wohlberg and Elizabeth Aub Reid
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