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THE REPRESSION POLEMIC: CONSTRUCTING NORMALCY
AND DEVIANCE WITHIN THERAPY DISCIPLINES
A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY
UNIVERSITY OF FLORIDA
I dedicate this dissertation to my parents, Pansy Anna Kelly-Ryan and Venice
Alton (Pete) Ryan, Sr., who have dedicated their lives to their children. I also dedicate it
to Eric Lee Ryan and Wesley Gilbert Ryan, my children, who have filled my heart and
thoughts with joys and pains every day of my adult life. My brothers and sisters (Alton,
Danny, Kay Ryan-Niemeyer, Louis, Rita Ryan-Pinner, and Linda Ryan-Waddell) have
supported my efforts throughout, and cheered me in my endeavors. Finally, I dedicate my
dissertation to all of the non-traditional students who will join me in fulfilling the dream
of sailing the academic-scholar ship once again.
I received a tremendous boost from Dr. Lonn Lanza-Kaduce, chairman of my
supervisory committee. Dr. Lanza-Kaduce picked up on the depth and intricacies of
possibilities of the research and encouraged me, while giving me leeway to develop. His
assistance in the final stages of the writing verged on heroic. The advice and assistance in
research of my other committee members (Dr. Ronald L. Akers, Dr. Richard Hollinger,
Dr. Constance Shehan and Dr. Joseph Spillane) contributed greatly to the success of this
dissertation. I cannot express sufficiently my gratitude for Dr. Terry Mills and Dr. Chuck
Peek, who saved me by substituting at the last minute when a member could not be there
during my hearings. The thoughtful suggestions and review by all the above have helped
keep me focused while confronting the confounding morass of inter- and intra-
disciplinary, micro/macro research. Dr. Jaber Gubrium also provided a tremendous
amount of information and assistance on the qualitative elements of the dissertation while
he was at the University of Florida. While I was happy at his promotion to chair another
sociology department, I sincerely regretted his absence for the final stages of the
I do not know how my dissertation would have been completed without the
sociological discussions with my friends, Dr. Sylvia Ansay, Dr. Amir Marvasti, and Dr.
Erica Owens. On numerous occasions when complicated concepts and hard and
discouraging days cooled the embers of my endeavors, they stoked my passion by
providing sorely needed compassion, insightful observations and helpful suggestions.
Drs. Felix Berardo, John Scanzoni, and Hernan Vera all offered me advice and
encouragement to complete this work even though none were on my. I am very grateful
for the assistance and advice on teaching issues tendered by Drs. Marian Borg and Chuck
Peek. Without their help I would have needed hours and hours of time away from my
dissertation. I am deeply appreciative of the devotion to scholarship and to graduate
members of the Sociology Department exhibited by all these professors.
Drs. George Lowe and Charley Peek of Texas Tech University were instrumental
in the earliest phases of planning my dissertation; and their concern from afar was very
heartening during many times when my progress was less than I hoped. Many unnamed
professors at both Texas Tech University and the University of Florida provided
encouragement through their own exemplary scholarship and devotion to academia.
TABLE OF CONTENTS
ACKNOWLEDGMENTS .......... ,, .....,, .......... iv
ABSTRACT ......,,,.........,,, ........., viii
1 INTRODUCTION .......... ............. .......
2 THERAPISTS' CONSTRUCTIONS OF THERAPIST DEVIANCE .. .. .. .. 7
"Soft" Reactive Defilnition of Deviance .. . . .. . .. 8
Constructionist Versus the Essentialist View of Deviance .. .. .. .. .. .. .. .. 16
Elite-Engineered Deviance? ......... . .. . .. .. 18
Formal and Informal Labeling of Therapists ... .. .. .. .. .. .. .. .. .. 18
3 HISTORY OF NORMALCY, DEVIANCE, AND CHANGE IN THERAPY 22
Therapy and Change ........... .... ., .......... ...,.........22
Emergence of Modern Psychiatry, Psychology, and Social Work . . 24
Variety of Therapies: The 20th Century . ... ... .. .. .. .. 29
4 REGRESSION POLEMIC ............... .................. 39
TheDebate ........... .. ...... ...... ...........39
Contexts of Therapy-Assisted Self Construction .. .. .. .. .. . .. .. .. 43
Consequences for Therapists and Clients . . .. .. .. . 47
Labeling and Imputing Victimization . .... .... .. .. .. 50
5 METHODS ............... ......... .............54
Subj ects/Interviewees/Resp ondents . ...... ..... .. .. . .. 5 6
Interviewing ............., .............. ......,58
AnalyzingInterviews ............... ....................62
6 ORIENTATIONS TO THERAPY ............... .............. 65
Interviews with Licensed Clinical Social Workers .. .. .. .. .. .. .. .. 66
Overview of How LCSWs Define Therapy Practices and Therapists .. .. .. .. 76
Interviews with Psychologists and an Educational Counselor .. .. .. .. .. .. .. 81
Overview of How Psychologists and a Counselor Define Therapy Practices and
Therapists ......... .............. ...........95
Interviews with Psychiatrists . . . . . 101
Overview of How Psychiatrists Define Therapy Practices and Therapists .. 107
7 MEMORY, SUPPRESSION, AND REPRESSION . . .. ... 109
M.S.W.s on Memory, Repression, and Regression Therapy .. .. .. .. .. .. .. 126
Ph.D.s on Memory, Repression, and Regression Therapy . . .. 126
M.D./Ph.D.s on Memory, Repression, and Regression Therapy . . 127
8 ACCOUNTABILITY AND ETHICS . .... .. .. .. .. 129
M.S.W.s on Accountability and Ethics . . .. .. . 140
Ph.D.s on Accountability and Ethics . ..... ..... .. . .. 141
M.D./Ph.D.s on Accountability and Ethics .. .. .. . ,. .. .. .. .. 142
9 LEGALISSUES AND THERAPY ............... ............. 143
Certification and Licensure ......... .. ..... . .. 145
Ramona v. Isabella and Third-party Suits . . .. .. .. .. 158
Mandatory Reporting of Abuse ......... .. ...... .. . .. 170
10 CONCLUSIONS AND DISCUSSION ............. ...........182
Orientations to Therapy .. .. . .. ..... . .. .. 183
Importance of Memory, Suppression, and Repression .. .. .. .. .. .. .. .. .. 186
Accountability and Ethics ............... .............. 188
Legal Factors ............... .......... ...........191
APPENDIX ............... ..........................193
A CONTACT LETTER ............... .............. ... 193
B INFORMED CONSENT FOR INDIVIDUAL INTERVIEW . . 194
C DEMOGRAPHIC DATA .......... ,, .... ....,,.....196
D CONTACT PHONE CALL .............. ............... .197
E TYPES OF PROBES USED ............... .............. 198
Topics (With Possible Questions) ....... .. ... .. .. .. 198
Issues .......... ...........200........
F UNDERSTANDING THE SUBJECTS' PERSPECTIVES .. .. .. .. .. .. .. 202
Language of Moral Exactitude ......... .. .. .... .. .. .. 202
Language of Precision ......... . ... .. .. .207
REFERENCES .......... ...........211........
BIOGRAPHICAL SKETCH ......... . . .. .. .219
Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy
THE REPRESSION POLEMIC: CONSTRUCTING NORMALCY
AND DEVIANCE WITHIN THERAPY DISCIPLINES
Chair: Lonn Lanza-Kaduce
My research adds to the sociology of deviance. Labeling and reactions to
deviance by therapists are examined. The debate over orientations toward the discovery
of repressed memories, and reactions to this debate, are used as a starting point for this
examination of how deviance is constructed by therapy practitioners. Interviews of
certified and/or licensed practitioners in the three major therapy disciplines of mental
health (clinical social workers, clinical psychologists, and psychiatrists) are subjected to
This inquiry discusses the narratives of ten therapists who revealed four major
areas for conceptual analysis. These are orientations to therapy; memory, suppression and
repression; accountability and ethics; and the interaction of legal issues and therapy.
While little difference was found between the narratives when examined by discipline,
arenas of individual differences were uncovered.
Training did not seem to affect orientations to therapy. The therapists all related
narratives stressing problem solving in the present. Their definitions of good practice
included maintaining confidentiality, doing no harm to the client, and following an
agenda coming from and about the client rather than the therapist. Few of the therapists
used any practices that are essential for extracting repressed memories. The line between
normative practices and deviance was seen to be crossed when the above were violated.
While professional and legal sanctioning of deviant actions was advocated, the
therapists who commit breaches were seen as impaired. Remedy was expressed in terms
of how to get these individuals "repaired" and back to normative practice. Organizational
or institutional remedies were seldom recommended (e.g., change in socialization, closer
monitoring by local boards, national registries of deviance, etc.). Reclamation rather than
proactive action was advanced in all but two interviews. Conducting the research also
provided insights into problems encountered in cross-disciplinary study--namely the
study of therapy discipline (and effects of legal sanctioning) from a sociological vantage.
This dissertation examined how the labeling of deviance is affecting mental health
therapy. It contributes to understanding the construction of deviant therapy practices. To
this end, it considered the following: how therapists with different training and various
kinds of practices think about deviance in their work (i.e., how they draw the line
between "good" and "bad" applications/therapists); how professional ethics and training
affect therapists' constructions; and how therapy and legal developments that regulate
practice play off each other. Because important legal developments have keyed on
childhood sexual abuse and the discovery of memories, the controversy over regression
techniques that recover "repressed" memory provides a strategic site for studying how
deviance is constructed and normative practices affected.
Before the 1960s, the term "child abuse" was not in general usage. In 1967 there
were 7,000 cases of reported child abuse and neglect, but by 1981 there were 1.1 million
reported; and in 1989, 2.4 million (Hacking 1991). Child abuse had to be constructed as
deviance (Pfohl 1977), and was responded to accordingly. Not surprisingly, part of the
reaction to the problems associated with child abuse involved therapy. Some therapy
techniques were expanded or developed, including regression therapy, to meet the needs
of victims. Because the discovery of child abuse reflected changing definitions and
constructions as much as abusive behaviors, many victims entered adulthood without
having had their abuse treated or even recognized. The promise of regression therapy was
that it could address how past abuse was a factor in current problems.
The increase in the popularity of regression therapy can be documented. A review
of the professional and academic journals covered in Sociofile reveals that before 1965,
only one article contained the word "repression." From 1965-1975 there were 142
entries, 1976-1985 contained 483, and 1986-1995 had 672 entries.
This dissertation takes advantage of the changing constructions of child abuse to
study controversial therapy techniques and shed light on how the delivery of therapy may
be constructed as deviant. The concept of "Repression" as used in this research involves
lessening access to an unpleasant memory with the following characteristics: 1)
traumatic or negative events occurred to the person, 2) memory of that/those events
cannot be recovered by normal memory processes, 3) the repressed memory affects the
person's present behavior, and 4) the way to cure the effects of repression is to make the
event conscious and relive it.
My study adds to the sociological tradition of studying the construction of
deviance and the effects of deviance labels. Some examples of research in that tradition
illustrate the wide range of topics that informs our knowledge about deviance. Erikson
(1966) examined the construction of witchcraft by Puritan society. Construction of
deviance between officers by police internal organizations was studied by Punch (1985).
The construction of computer crime by lawmakers was detailed by Hollinger and
Lanza-Kaduce (1988). Gubrium and Holstein (1990) found that deviance in families can
be constructed by therapy organizations. Construction of addiction by practitioners and
researchers was recounted by Akers (1991). Holstein (1993) found that mental illness can
be constructed by attorneys in competency hearings.
A more complete exposition of how the study of therapy fits within a
comprehensive deviance framework is presented in the next chapter. By way of
introduction, suffice to say that the study of deviance poses two central issues according
to Akers (1977, 13) "how and why certain kinds of behavior and people become defined
and reacted to as deviant" and 2) "how and why some people come to engage in actions
or acquire the characteristics defined as deviant." Much of the study of deviance and
crime focuses on the second issue. The labeling or social-reaction perspective draws our
attention to the former, and focuses on "the behavior of those who label, react to, and
otherwise seek to control offenders" (Cullen & Agnew 2003, 295; emphasis in the
Social groups create deviance by making the redes whose infraction
constitutes deviance, and by applying those rules to particular people and
labeling them as outsiders. From this point of view, deviance is not a
quality of the act the person commits, but rather a consequence of the
application by others of rules and sanctions to an "offender." The deviant
is one to whom that label has successfully been applied; deviant behavior
is behavior that people so label. (Becker 1963, 9; emphasis in original)
The labeling perspective is similar to the conflict approach in emphasizing the
formation and application of definitions. Indeed, the two approaches have become so
closely identified in arguing that social interactions to deviance are unequally applied
against the less powerful groups that some sociologists see conflict and labeling theorists
as almost interchangeable (Hagan 1973, Wellford 1975).
The question of how labels are applied, therefore, revolves around the issue of
power. The behavior of less-powerful groups or individuals is more likely to be defined
as deviant; more-powerful groups or individuals are in a better position to resist labeling,
or to negotiate when or how behaviors are labeled (Hawkins & Tiedeman 1975).
The study of therapy and therapists involves groups and individuals that possess
education, status, and some level of power. They are not free to disregard external efforts
to regulate their practices and must work within the existing legal structure. As
professionals, they enjoy considerable autonomy over their work, and belong to
professional associations that are often successful in insisting on self-regulation through
certification and codes of ethics.' When professionals fail to regulate themselves
sufficiently, there is great pressure for external constraints.
Therapists hail from different training backgrounds, and therapy cuts across
different disciplines and schools of thought. Abbott (1988, 325) reminds us that we must
"start studying work" rather than the profession. He calls for the study of the history of
the work, who was involved and where they came from, how markets for their services
were created, and how conflicts shaped those who practiced.
Deviant therapy practices are the concern of both professional associations and the
law. The professional associations to which therapists belong promulgate ethical codes
and standards of practice in an effort to regulate therapists and therapy. Professional
associations also provide certification. Such efforts represent a form of self-regulation.
My study focused on how the practice of therapy has been affected by this self-regulation,
SCodes of ethics for therapists are similar to each other. These codes can be found through the national
organizations or online at:
1) National As sociation of Social Workers: http ://www.socialworkers .org/pub s/code/code.asp
2) American Psychological Association: http ://www.apa.org/ethics/code2002 .htin1
3) American Psychiatric As sociation: http://222.p sych.org/apa_1einbers/ethics~opinions53 10 1
and what this effect on therapists has done to change conceptions of mental health
Deviant therapy practices can also give rise to legal controls that go beyond
self-regulation by the professional associations. One way this control is exerted is
through state licensure. Legal controls have also been imposed through court cases [e.g.,
Tarasov v. Regents of the Universityi of California (1976) and Ramona v. Isabella (1 994)]
and through legislation (e.g., mandatory reporting of abuse). Although therapists have
long been accountable to their clients for deviant practices, more recent case law has
established their potential liability to others. Tarasov was a landmark case in which a
therapist was held liable for his client's injuries to a third person because the therapist
failed to report credible threats made by his client. Ramona established that therapists
could be held liable in tort for damages caused by a client's accusations stemming from
therapy techniques which manufactured memories of childhood sexual abuse. Statutes
now mandate reporting of suspected child abuse, creating a quandary for therapists. They
are required to report suspected child abuse, but need to determine which accounts are
credible to stay within strictures to maintain the client's confidentiality. In the process,
they are potentially liable for tort suits if their techniques lead to false or unreliable
accounts of abuse. The legal problem is compounded by the power differential between
therapists and clients, and by different levels of suggestibility in clients. The role of court
cases and public awareness may be affecting therapists' practices in these disciplines, as
explored in the interviews. One focus of this study is on how the practice of therapy has
been affected by these legal controls and professional guidelines.
My research analyzed interviews with licensed and/or certified therapists to
investigate how the labeling of deviance within the institution of mental health is done
(constructed). This approach used narrative analysis, supplemented by content analysis
and conversation analysis. Cards that identified concepts frequently found in the
literature were offered to the interviewees. The interviewees' selections helped structure
the narrations. The goal was to allow them to define the concepts, set priorities for the
interviews, and minimize the interviewer's role. Accordingly the interviews were loosely
structured, but all of them provided for narrations on a series of topics: 1) orientations to
therapy; 2) memory, suppression, and repression; 3) accountability and ethics; and 4)
legal issues and therapy.
STwo types of deviance and two types of construction are discussed in this dissertation. The type of
deviance that is focal is deviance within therapy, which can mislead or harm clients and others. This type
of deviance is contrary to the ethical standards of each of the therapy disciplines and sometimes is
actionable. The deviance of perpetrators of childhood sexual abuse is also an element discussed in this
The construction that is focal involves how the therapist-respondents construct how therapy
should be done, and which therapy practices and therapists are labeled as deviant. Unfortunate for the sake
of clarity, the deviance of persons who commit childhood sexual abuse and the therapeutic method of
constructing a new life by confronting a past event are also essential factors. Rather than label them as
type "A" or type "B" or some other artificial demarcation, context within my text indicates which types are
under discussion in a particular segment.
SAn institution has been defined sociologically a "a major sphere of social life, or societal sub system,
designed to meet basic human needs" (Macionis 2004, 301); as "a collective solution to a problem of social
life [that] includes a variety of groups and organizations that address a problem of social life" (Lauer &
Laurer 1998, 124); and also as "stable set of roles, statuses, groups, and organizations .. which provides
for behavior in some major area of social life" (Newman 2000, 29). Mental health can be conceived as a
social institution under each of the above definitions:
A. The way of behaving is through the theory and organization of psychology. The human need is
B. The problem of social life is maintaining an efficient populace and workforce.
C. The social structures (roles, statuses, groups, and organizations) are found in the disciplines that
include psychiatry, clinical psychology, and clinical social work--all of which have similar ethical
standards of action but different statuses, functions, and ways of interaction in pursuit of their common goal
of treating mental illness and, sometimes, providing theoretical and methodological resources for the
maintenance of mental health. The culture is a merged one stemming from neurology and psychological
foundations. Finally, the technologies of the institution of mental health are those which have evolved and
are evolving from neurology, psychology, and the needs of public service.
THERAPISTS' CONSTRUCTIONS OF THERAPIST DEVIANCE
The study of deviance confronts the problem of defining deviance and identifying
who is considered deviant. Goode's exposition (1994, 1997) presents a framework for
considering deviance and therapy. His framework begins by discussing approaches to
defining deviance. Goode (1994, 12-15) rejects five "naive" and/or "misleading"
definitions based on absolute moral standards, statistical analyses, social harm,
criminality, and "positive" deviance. He then concentrates on two "fruitful (but flawed)"
approaches that focus on social norms (normative definition) and social reactions to
behavior (reactive definition). Goode notes that the normative definition is the most
commonly accepted approach.
"Norms define appropriate acts and conditions for a society's members" (Heitzeg
1996, 3). "The normative definition locates the quality of deviance not in actions or
conditions themselves but in the fact that they violate the norms of the culture or
subculture in which they take place and exist" (Goode 1994, 15). It "locates deviance in
the discrepancy between an act or a condition and the norms" present at that place at that
time (Goode 1994, 16). Goode also notes that it implies relativity-norms will differ from
group to group and time to time. "What makes a given action or condition deviant is the
fact that it is a violation of the custom, rule, law, or norm when and where it occurs."
(Goode 1994, 16).
One of the major problems that Goode (1994, 16) links to the normative definition
is that it "ignores the distinction between violations of norms that generate no special
attention or alarm and ones that cause audiences to punish or condemn the actor." For
over 80 years, social scientists have noted that relatively little attention has been paid to
societal reactions to deviance (Dewey 1922, Kitsuse 1968). The reactive definition
addresses that omission. "What makes an act or a condition deviant .. is how it, and the
individual who enacts or possesses it, are reacted to by actual people, audiences, or others
who punish or condemn the individual" (Goode 1994, 17). The reactive definition of
deviance requires "actual, concrete instances of punishment and condemnation" (Goode
1997, 26). One of the major problems with over-reliance on the reactive definition is that
it de-emphasizes the original behavior or condition that gives rise to the condemning or
punishing reaction. For example, Akers and Sellers (2004) argue that labels are attached
to behaviors and that deviance cannot be studied by only looking at the social reaction.
"Soft" Reactive Definition of Deviance
Goode offers a compromise by adopting a "soft" or "moderate" reactive approach
to defining deviance, the construction of deviance, and reactions to deviance.
In sum, by deviance, I mean .. behavior or characteristics that some
people in a society find offensive or reprehensible and that generates--or
would generate if discovered--in these people disapproval, punishment of,
condemnation of, or hostility toward the actor or possessor. Goode 1997,
Goode (1997) adopts his "soft" reactive definition of deviance to incorporate three
features that he claims advance the conceptualization of deviance. First, since no rules are
absolute, "one should be able to infer from reactions by a wide range of audiences to
behavior and conditions what the norms are" (26). One of the goals of this dissertation is
to learn from therapists what "the norms are." That includes general normative
orientations to therapy that contextualize understandings of deviance in therapy. The
interviews explore how therapists understand the norms and how that reflects various
audiences. Goode notes that "It is the audience which determines whether something or
someone is deviant: no audience, no labeling, therefore, no deviance" (Goode 1997, 107).
A second advantage that Goode (1997, 26) claims for his soft reactive definition
of deviance is that it recognizes that "the enactor of potentially deviant behavior, or the
possessor of potentially discrediting characteristics must operate in a sea of imputed
negative judgments." Another of the goals of this dissertation will be to explore, from the
perspective of the therapists, how reactions by audiences affect the therapists' norms and
The third advantage is that the soft reactive definition allows Goode to escape
from the dilemma presented by "secret" or undetected deviance. If most norm-violating
behavior or conditions remain undiscovered, they are not reacted to. To the strict
reactivist, they would not be deviant. On the other hand, the normative approach, which
defines secret norm violations as deviant because they would be reacted to if they were
discovered, misses the important role that social reaction has in contributing to their
stigmatized status. "Although social reaction does not create the actual behavior ...., it
does lend to it a stigmatized status, and it influences certain features of that activity and
the lives of men and women who engage in it that would be lacking in the absence of
negative labeling" (Goode 1994, 21). Goode concedes that "the reactions of audiences
do not necessarily create the behavior in question out of thin air," but that social reaction
affects people who engage in that behavior regardless of whether their deviance is
detected. Secret deviance plays a role in forming the norms which other individual
therapists (as members of the audience) profess and that are revealed in their practices. A
goal of the dissertation is to learn about reactions by therapists to various therapy
practices and practitioners, regardless of whether norm violations have been detected.
What do therapists react to strongly when it comes to deviance within their ranks?
The literature on deviance suggests that Goode could have gone further in
developing the point. Social reaction has social utility in several ways. Durkheim
(1893/1933) noted how it could reinforce shared norms. To him, shared norms rather
than threats of punishment, were functional for social control. Erikson (1966)
demonstrated how social reactions helped establish and maintain the moral or normative
boundaries for groups. In this sense, social reactions to deviance are educative for those
who are compliant as well as those who are deviant. A goal of this dissertation will be to
explore how various social reactions to therapy practices and therapists, including some
official legal and professional reactions, have affected therapists' own views about
deviance and practice.
Audiences play a critical role in Goode's discussion. Their reactions help identify
the norms, and actors have perceptions about how various audiences feel about deviance.
Goode identifies different potential audiences at different levels of analysis-individual
actors, potential victims, social intimates, witnesses/bystanders, members of small
groups, societal members, formal social control officials and systems, and distant
observers. He notes that "attitudes toward and reactions to potential deviance are held
and expressed by people with vastly differing degrees of power-power to have their
views of what is right and wrong win out over those of other people" (Goode 1994, 23).
He goes on to assert that what needs to be known is "which forms of behavior and what
conditions stand a high chance of earning condemnation and punishment for the
Goode identifies three dimensions that determine the likelihood of something
being labeled deviance: the numbers who are likely to punish or condemn a phenomenon,
the power of those who disapprove of the phenomenon, and the intensity of their beliefs.
Punishment or condemnation is more likely to occur if more people define something as
deviant, if they have relatively more power, and if they hold strong beliefs about the
inappropriateness of the deviance.
The centrality of the role of audiences in labeling deviance becomes more
complicated by the challenge of relativity that Goode incorporates into his approach. He
notes that audiences are relative and the "greatest amount of variation occurs from one
specific person to another" (Goode 1994, 25). The relativity in audience is compounded
by relativity in individual actors and situations. Some individuals are in better positions
to resist deviance labels. "High status individuals are allowed a great deal more leeway in
what they do and are; they aren't judged as harshly as lower-status people are, and they
have resources to deflect criticism that might be headed their way" (Goode 1994, 27).
Erikson (1962) indicates that some who engage in behavior that is labeled as deviance
can avoid being labeled as deviant individuals. Similarly, some situations are more likely
to escape labeling. "The setting makes a great deal of difference in how audiences judge
behaviors, actors, conditions, and their possessors" (Goode 1994, 28).
The settings of therapy have been examined by others, elements such as the
effects of the "fifty minute hour," therapists not providing answers to direct question but
asking questions as a response to questions they are asked, etc. (Lindner 1955, Goldman
1996, Frank 1998, Frawley-O'Dea 1998). Other major elements of the social
environment which bear upon therapists are found in legal rulings, the organizational
structure and messages of their discipline, and the media exposure of actions and attitudes
of public opinion.
One variation on relativity is potentially important to a study of deviance in
therapy. Individual therapists may know of acts which have been labeled deviant through
societal normative standards (law and ethics boards) and even know of therapists who
have been sanctioned and stigmatized for these acts (or who could be). Yet, some
therapists may be reluctant to affix the deviance label. The research explores whether
therapists distinguish between the act of deviance and the deviant actor-they may be
willing to condemn the sin but not the sinner. They may grant wide berth to many
practices and other practitioners. Therapists may be slow to judge fellow therapists since
all therapists are potentially vulnerable to errors of professional judgment and few may
want to have their own professional judgment questioned or reacted to strongly.
Moreover, therapists may be reluctant to put their occupation in a bad light. Airing even
others' dirty laundry in public (i.e., opening the therapy relationship to consideration by
other audiences such as the media) may hold implications for themselves as well as for all
therapists. The analogy would be to the "blue curtain" that insulates law enforcement and
the concomitant reluctance of police to report the deviance of fellow officers (Westley
1970; Crank 1997). The interviews will shed light on how therapists react to potential
Changes in therapy (discussed in more detail in the next chapter) may affect how
therapists label deviance and deviant practitioners. The introduction of Rogerian therapy
stressed unconditional positive regard. As behaviorist and problem-solving therapies
became commonplace, the focus centered on current behaviors rather than intrinsic traits
or past conditions. The actors are not labeled as bad, and the behaviors are to be treated
or mitigated, not condemned. Has the ethos of therapy change enough so that therapists
do not view behaviors generally as matters of deviance--including professional
behaviors? Has a new ethos developed so that actors are not seen as deviant even if
problem behaviors are?
The study of deviance among therapists raises some questions about audiences,
actors, and situations. Although many people may condemn blatant abuses of therapy
relationships (e.g., having sex with clients), other aspects of practice may be much less
clear-cut. Victims may not be a large or powerful audience in the attribution of deviance
in therapy. As clients, they seek therapy because of various problems which are often not
concrete; treatments and outcomes are not standardized. The independent professional
judgments that therapists are expected to exercise are necessary given the uncertainty
surrounding the therapy context. Clients also have relatively less power than the
"experts" they seek out, and they are not in a good position to know about which therapy
practice will or will not help them. The uncertainty may be functional for therapists in
that members of the larger society are not in good positions to condemn various
techniques and practices that may be especially tailored to fit the particular needs of a
client. In other words, the number of potential condemners is reduced, they lack the
expertise (and hence the power) of the professionals who practice therapy, and they are on
grounds too shaky for strong condemnation.
The exalted prestige, autonomy, deference to professional judgment, and latitude
in self-regulation and judgment that have been available for psychoanalysts and other
regression therapists may be at risk. Reflection and reflectivity are undoubtedly occurring
among psychoanalysts and regression therapists as they confront changes in social
conditions described above. The labeling of parts of regression therapy as deviant has
cast a shadow on therapists who use these techniques. Since this was the main
perspective of psychiatry at the height of its professional dominance, denigrating this
practice may have contributed to some of the loss of its dominance over the other
disciplines and other, less formal types of therapy.
The issues are compounded by the norm of confidentiality in therapy
relationships. Indeed, breech of confidentiality may be one of the normative violations
that is condemned (and condemned strongly) by many people, including other therapists
and powerful social control officials. Confidentiality allows for instances of deviance
within therapy to remain secret. Moreover, "victims" of deviant therapy who think about
reporting the therapist face some constraints. Those in therapy are suspected of having
coping or mental issues, which may be stigmatizing in themselves. Their private
problems become public concerns if they report, and they may be less credibly received
than would be the professional if a dispute arises about what happened. Moreover,
therapists derive power from their formal training and their individual experience of
framing issues (which is a component of their work). They are uniquely in a position to
present a case that puts them in the best light--they can use their expertise to discredit
client behaviors and cast doubt about motives of clients making accusations.
Therapists constitute a key audience for learning about the norms and social
reaction to potentially deviant therapy practices. They may be engaging in deviant
practices, reacting to the deviance of other therapists, or adjusting their own practices
because of broader social reactions to deviant practices or practitioners.
Goode's lessons about relativity suggest that a study of deviance in therapy needs
to explore across different kinds of therapists and different situations. Therapists can
vary by type of training (e.g., social work, psychology, psychiatry), extent of training
(e.g., MSW, Ph.D., M.D.), nature of practice (e.g., solo, group, self-employed, salaried),
and nature of clientele (e.g., specialty populations like children or the elderly versus
Another key audience for the study of deviance in therapy arises within the
official social control system. Some of the social reaction that is important for
understanding deviance in therapy emanates from official social control agents. Indeed,
formal social control reverses the power arrangements in ways that may affect
perspectives on deviance. Professional practices are regulated by law and by professional
groups which promulgate ethical standards for their members. However, different
states/jurisdictions can advance different laws (e.g., psychiatrists in Florida will work
with different laws from those in New York) and different professional associations can
present different standards for therapists (e.g., psychiatrists will belong to different
associations than will social workers). This contributes to the perception of the nebulous
nature of normative definitions. Given the relativity, therapists may have different
understandings about deviance in their workplaces.
Goode asserts that "it is important to identify the party [or parties] judging the
behavior or condition .. the relevant audience" (Goode 1997, 29). In addition to the
legal system which serves as an audience, the national, state, and local organizations of
therapy disciplines (see footnote 1) intervene to prevent outsiders including moral
entrepreneurs from regulating their practices [persuasive, legitimate, active, credible
figures who launch a campaign to discredit an activity (108)]. The societal norms for
therapists are prescribed or proscribed through the formal standards of ethics of each of
these therapy disciplines. Other components of the audience are the therapists who are
labeled, their clients and victims and their social intimates, other direct observers of the
act(s) judged deviant or of the labeling process, members of the mass media, members of
society who follow the process through media, and others who read or hear about the
behavior labeled deviant but are at a social distance precluding their being influenced by
the judgment in any way. Some "parties or audiences, from the participant to the
detached observer, would condemn the behavior, the condition, the actor or the possessor,
were they to come face to face with them" (28-9).
Constructionist Versus the Essentialist View of Deviance
Goode (1997) rejects an essentialist view of deviance-one which holds that
essential differences exist which can be used to categorize phenomena, including
deviance. Instead he adopts a moderate constructionism which recognizes that many
categories are social and mutable rather than derived to reflect inherent properties or
"essences." The constructionists hold that "definitions have no absolute, objective
validity; they are meaningful only within the context of the criteria spelled out by a
particular classification scheme" (Goode 1997, 34).
Constructionists expect that social conditions evolve. For example, they would
expect therapy to change and the problems therapists deal with to change. Definitions of
deviance in therapy are also expected to evolve as problems develop and norms shift.
The changes may occur at the therapist level (e.g, individual reactions and responses to
issues and vicissitudes of practicing in an otherwise changing social and physical
climates), at the mental health institutional level (e.g., imposition of revised standards and
sanctions by the therapy organizations), and/or at the inter-institutional level (e.g.,
reactions to emerging laws and to exposure by the media).
The discovery of child abuse generally (Pfohl 1977) and the ongoing discovery of
sexual child abuse created a new context and prompted change in the larger society and
among therapists. Mental health professionals spent multiple hours accessing
client/patient's memories as a first step in transforming a client/patient's dysfunctional or
unhappy life. Their present problems are rooted in past events so that memories seem to
hold the key for successful interventions. An institutional familiarity with Freudian
techniques and notions of repression may have also contributed to a concentration on
efforts to locate memories of those who had been victimized by child abuse. Regression
therapy and the search for repressed memories was de rigeur for therapy. The public
awareness and the estimated prevalence of childhood abuse suggested an explosion in
perceptions of numbers of possible victims, making it more necessary for therapy. The
techniques used to explore these memories has given rise to successful lawsuits by third-
parties who were directly affected by the therapy sessions.
"Defining behavior as deviant is variable with respect to the degree to which it is
spontaneous and grass-roots or organized and engineered" (Goode 1994, 56). The
literature provides little evidence of any kind of spontaneous grass-roots groundswell to
rein in deviance in therapy. Instead, the social reaction emanated from courts,
legislatures, and professional associations which were the guardians of professional
standards of ethics. The attribution of deviance, whether of particular therapists or of
treatment practices, is most manifest in changes in the ethical standards and in the
imposition of laws that affect the procedure of therapy. In other words, the definitions of
deviance played out at elite levels. The legal and professional developments occurred
during, and may have been encouraged by, an academic conflict among psychologists
about the utility and validity of work on the repression of memory (see chapter 4).
The increased attention given to repression by the media was documented in
chapter 1. The institution of media helped spark popular, legal, and therapy recognition
and interest in the changing cultural norms of therapy practices and in practitioners who
deviate from these norms. It reports salient legal issues and plays a role in making salient
the cases that reflect these issues through broad exposure. Public attention was focused
on the problems that media highlight, including the discovery of child abuse and concerns
about sexual child abuse. This attention brings other institutions into play as the examine
the issues and problems from vantage of their separate and unique perspectives.
Formal and Informal Labeling of Therapists
State and federal statutes can be used for official labeling. Federal law mandates
the reporting of suspected abuse [Child Abuse Prevention and Treatment Act (CAPTA)]
which was originally enacted in 1974 (P.L. 93-247) and was last reauthorized on June 25,
2003, by the Keeping Children and Families Safe Act of 2003 (P.L. 108-36)]. Many
states have similar provisions in their codes.
Formal labels emanate from court cases. The courts act as an audience which
applies deviant labels directly to therapy and therapist. These formal norms govern 1)
therapists' testimony when called as expert witnesses, 2) prohibition of use by
prosecutors of information attained by some therapy techniques which increase client
suggestibility and can create false memories, 3) mandates to report suspected abuse or
danger to self or others by therapy clients/patients, and 4) the tolling of the statute of
limitations for torts experienced when a child.
Chief among the rulings which directly apply to therapists and techniques labeled
deviant are the Tarasoff and Ramona cases. In Tarasoff v. Regents (1976) the court
mandated a therapist to report possibilities for harm by the client which are discovered in
therapy or be held liable for damages which the client causes.
Ramona v. Isabella et al. (1994) first held therapists accountable to third-party tort
suits.' The court awarded both compensatory and punitive damages.
SThe cases cited in the text are the omnibus cases relating to harm that therapists can prevent or that they
can instigate. There are many cases which have been cited in the articles concerning regression and
repression of memory that have provided precedence in suits arising from alleged damage precipitated by a
therapist. The following are a few of the more notable that involved liability to third parties damaged as a
result of deviant therapy practices:
A. Couch v. DeSilva (602 N.E.2d 286 Ohio 1991) (mishandled recovery of memory by therapist)
B. Doe v. McKay (678 N.E.2d 50 (Ill. App. Ct. 1997) (tort for loss of consortium occasioned by
C. Dillon v. Legg, 441 P.2d 912 (Cal. 1968) (en banc) (patient acknowledged misdiagnosis that could
be used by injured third party to establish liability of therapist)
D. James W. v Superior Court (93 C.D.O.S.5449 Jul 16, 1993) (denial of immunity from suit about
unfounded charges by client against a third party)
E. Mateu v. Hagen (King County Superior Court, 91-2-08053-1 Seattle) (therapist's use of age
regression, bioenergetics, psychodrama, trance work, visualization, and guided imaging was overly
In addition to the legal rulings which affect therapy, there are legal rulings which
result from changes that have occurred in the practice of therapy. Among these are those
which deal with therapists as expert witnesses and those which result from some of the
techniques of therapy disclosed as potentially aberrant by the national media [e.g., the
McMartin case of New Jersey (McMartin, Virginia, et al. v. Children's Inst., et al. 494
U.S. 1057; 110 S. Ct. 1526; 108 L. Ed. 2d 766; 1990 U.S.), the Franklin case [Franklin v.
Duncan (WL 684390 9th Cir. 1995)], and the Ingram case [Raymond v. Ingram 47 Wash.
App. 781, 737 P.2d 314 (1987)]. For example, in many jurisdictions testimony will not
be admitted that is based on information the plaintiff or prosecutor retrieved via hypnosis
or psychoactive drug treatment. Therapists whose testimony is based on knowledge
gained from these techniques will not be qualified as expert witnesses.
For this dissertation research, only those rulings which directly pertain to the
practice of therapy (Tarasoff and Ramona) were specifically raised in the interviews.
Arguably, some other cases have had a salient informal effect on therapists and the
practice of therapy. The interviews provided the opportunity for therapists to volunteer
which rulings or law affected their thinking about deviance in therapy.
The institution of mental health is also involved in formally defining deviance.
Each of the therapy disciplines, in their standards of ethical practice cited in chapter 1,
includes an organizational injunction to do no harm (primum non nocere). Basing
therapy on a false premise potentially harms the client/patient when accepting and
F. Montoya v. Bebensee (761 P.2d 285, Colorado Court of Appeals, 1988) (duty to care for harm to
third party from foreseeable false charges)
G. Tyson v. Tyson (11986 Wash.2d) (delayed discovery and latent injury cases)
H. W.C.W v. Bird (840 S.W.2d 50 1992, Texas Court of Appeals) (problems with client's testimony
after use of sodium amytal)
focusing on memory which is a product of suggestibility rather than actual events.
Increasing client/patient suggestibility is adding another impediment into his/her life.
This creates a weltanschauung which must at some point conflict with reality and serve as
a barrier to adapting to present real situations and problems--one of the main purposes of
In addition to the harm done to the client/patient, having the client/patient act
upon findings elicited by questionable techniques to resolve a problem which did not in
actuality exist, even in the past, interferes with present interactions with others who were
included in the false memory. Third-party lawsuits can arise in situations where therapy
clients confront others as a result of the therapy that they receive.
Goode (1997) argues for a contextual construction of problems.
The contextualist constructionist's concern is mainly in understanding how
definitions of social problems are generated, sustained, taken seriously,
and acted upon; and how certain claims of seriousness are advanced by
specific agents and reacted to, or ignored, by different audiences. Goode
This orientation informs the organization of the next two chapters. In Chapter 3, I
examine how the social problem of dealing with mental difficulties has been generated,
sustained (or exterminated), taken seriously, and acted upon in the past. In Chapter 4, I
examine how regression therapy and repression techniques have become defined as a
social problem, how the problem is sustained by those therapists who use the techniques,
and how others attack the techniques as needing to be exterminated or modified, and I
indicate the seriousness of this problem. After a methodology chapter, the bulk of the
remaining chapters are concerned with data on how the audience of therapists view
therapy and deviance as well as react to the labeling as a problem.
HISTORY OF NORMALCY, DEVIANCE, AND CHANGE IN THERAPY
Therapy and Change
If the past is any guide to the future, today we can be certain of only one
thing: The day will come when people will look back at our current
medicines for schizophrenia and the stories we tell to patients about their
abnormal brain chemistry, and they will shake their heads and mutter in
disbelief. (Whitaker 2002, 291)
Organized concern for mental or emotional illnesses and therapy has existed in
America for only a little over 100 years (Napoli 1981). In 1892 the American
Psychological Association (APA) was formed, establishing a functional national
organization for therapists. While there were earlier attempts at centralization (some of
which lasted for years), only after the birth of the APA did America have a national
community of mental health specialists that has survived to the present. Since its
inception, and even though many of the therapeutic theories and methods advanced (or at
least tolerated by the APA) have later fallen out of favor,' the APA has consistently
received recognition as the dominant organization within the institution of mental health.
Distinctive eras of therapy before that unifying event are difficult to discern. The
practice of therapy did not have the organizational structure of an identifiable institution
required for tracing what has been labeled deviance as generations progressed. Indeed,
there was even less separation of physical treatments for disease and morbidity from
SA number of these previously discarded therapies are now at least marginally accepted and some members
of the American Psychological Association are protagonists of many of them. A few of these later
reappeared in modified forms--notably elements of the water-immersion therapies, electric shock therapy,
and many drug treatment therapies.
treatments of mental illness than is presently practiced. Distinguishing mental health
treatments from physical health treatments is generally impossible. The medical model of
health has predominated, and in early history was the only method in use (Ackerknecht
1955). The breadth and scope of differences between practices wielded by therapists,
then and now, compounds the difficulty in distinguishing eras. Presently, institutional
rules and guidelines do provide standards for making comparisons. There were no
institutional rules and guidelines in place before the founding of the American
Psychological Association--there were only centers for treatment, or disposal, of persons
who were having mental health problems.
The historical literature reveals how difficult it is to distinguish each historical
era. That difficulty extends to discerning which practices were considered normative.
Even today there are advocates and practitioners using many of the methodological
practices that were in place hundreds of years previously (before falling out of favor, and
in some cases being labeled deviant). Treatments still range enormously, from physical
interventions (such as administering pharmaceuticals or performing electroshock) to
interventions that include more nebulous factors (such as retrieving memories of past
Despite this lack of organization among therapists of the distant past and a wide
range of tolerance for diverse types of practice today, there is clear evidence of change in
the predominant theories and methods used in therapy during credibly distinct eras of
therapy. Therapy has a history of treatments and theories which have often been reviled
or regarded unfavorably by succeeding therapist generations. What may be regarded by
later therapists as deviance in treatment practices may have been regarded as a
breakthrough in knowledge. Indeed, some of these practices assumed leading roles in
treating mental illness (e.g., insulin shock therapy, lobotomies, and water emersion).
Individual therapists precipitated changes in the predominant methods of treatment in
their pursuit of solutions to mental and/or emotional problems that hindered normative
(or at least functional) adaptation to troubled social surroundings and self identities.
The factors which lead to therapy shifts are historically variable and are
complicated. In each era, individual practitioners adapt to these shifts in their own ways.
Their professional roles as therapists comport to the possibilities that are in that time
socially and structurally confining while adapting not particularly to a theoretical identity
but more to the practical standards which work for their clients and for themselves.
Emergence of Modern Psychiatry, Psychology, and Social Work
In the 19th century neurology and psychiatry split into separate medical disciplines.
These two were later joined by psychology as the disciplines most concerned with mental
health. This provided the infrastructure of the late 19th and the 20th centuries for building
and organizing disciplines for the regulation of diagnosis and treatment practices.
Modern psychiatry has been described as dawning at the beginning of the 19th
century (Marmer 1994). There was a return to the Hippocratic belief in the biological
basis of mental disorders, which was attended by the rise of psychiatry as a scientifically
organized discipline with roots in neurology. This somatogenic view focused on the
belief that pathological bodily conditions and brain tissue dysfunctions were solely
responsible for mental disorder. Mental illness thus became the exclusive domain of
physicians. Heredity became the salient variable for understanding mental health issues.
Psychiatry's Emergence from Neurology
While psychiatry had roots developed from humanists like Agrippa, Pinel and
Tuke (along with a few other isolated reformers of the nineteenth century) paved the way
for the transition of psychiatry into its present form. Their voices spelled the end of
justification of punishment for the mentally ill and provided for moral treatment and cure
through humanistic techniques.
The term "neurologist" came to refer to organic physicians generally
working in hospitals. Psychiatrists took over the neurologists' old position
as the outpatient border guard of the medical profession, handling the
symptoms and diseases that seemed not quite real. .. Psychiatry began
when a group of enterprising medical reformers argued in the early
nineteenth century that madmen ought to be removed from the jurisdiction
of the legal authorities and placed under that of the medical profession.
Madmen are sick, they said; give them to us and we will cure them. A
new theory and therapy justified the shift, and private bodies and state
legislatures were soon dotting the countryside with insane asylums.
(Abbott 1988, 22)
The Entry of Psychology
By the middle of the nineteenth century almost all American psychiatrists believed
that psychological problems had physiological causes (Cockerham 1992). Conventional
medical science resisted investigating how physical symptoms could proceed from
emotional causes (rather than the other way around) until Jean-Martin Charcot presented
a paper on hypnotism to the French Academy in 1882. While advancing a treatment plan
which took into consideration factors other than anatomy and physiology, his methods
produced problems of their own. Under Charcot patients came in with problems
[psychosomatic conversion symptoms, PTSD (post traumatic stress disorder), and other
emotional responses to their unhappy lives]. He gave them a certain degree of legitimacy
(even celebrity), but:
He took away their dignity and their hope. They were pressed into mass
conformity, put into solitary confinement, turned into chronic, even
lifelong patients. Through hypnotic suggestion .. hysterical patients
were already becoming iatrogenic monsters. (Showalter 1997, 36-7)
Loosening of the medical model of treatment proceeded steadily but slowly
thereafter. The greatest blow to the paradigm of the medical model was the one that set
therapy on a path emphasizing psychological concepts of personality, learning, and
motivation-psychoanalysis These concepts were j oined to the technique of hypnotism,
which had been first advanced a century before by F. Anton Mesmer (who has been
deemed the father of psychotherapy by psychoanalysts) (Ackerknecht 1955). The blow
was delivered by the writings of Sigmund Freud (originally a neurologist) and his early
coauthor, Joseph Breuer (discussed below in Chapter Three). Thinking about the nature
of mental illness was revolutionized by Freud and Breuner at the end of the nineteenth
century. Their "dynamic" psychology included patients who were neurotics as the
psychotics who had traditionally been treated by psychiatry (Horwitz 2002). "Dynamic
theories posited that neuroses were continuous with normal behavior" (Horwitz 2002, 1).
At the end of the century (1896) Arthur Rufus Trego Wylie was the first American
psychologist to be employed in a clinical setting. He later became superintendent of The
Institute for the Feeble Minded in North Dakota (Street 1994).
The Entry of Social Work
Psychiatrist John Conolly in 1856 wrote "The Treatment of the Insane Without
Mechanical Restraints" in England which was responsible for the growing disfavor
accorded that method of treatment on both sides of the Atlantic (Street 1994). Dorothea
Lynde Dix, arguably one of America's greatest humanists of the nineteenth century, was
instrumental in exposing deplorable and brutal conditions of the mental hospitals in the
U.S. during that time. "Through her efforts she personally founded or enlarged some
thirty-two mental hospitals ." (Cockerham 1992). She was the most influential
advocate of the principle of public responsibility for the mentally ill and got the mentally
ill out of jails and poorhouses into asylums. She also documented filth, brutality, and
degrading conditions in existing hospitals (Street 1994). Ironically, the numbers of
hospitals that sprang up under her influence and the enormous increase in the numbers of
patients decimated the ratio of experienced therapists-and-staff to patients, leading these
large mental hospitals to become more custodial than treatment-oriented. Neglect and
warehousing sometimes resulted, similar to that found in the 17th century but without the
Beginning in Boston in 1877, "charity organization societies" began investigating
problems of the poor and providing visits and advice to assist them (Kane 1983). Paid
positions and educational programs for what became social work practitioners developed
from these societies. By the turn of the century, settlement houses (e.g., Jane Addams'
Hull House in Chicago and Lillian Wald's Henry Street Settlement House in New York)
began addressing the social problems associated with health conditions and health
The physician who is generally considered to be the founder of medical social
work, Richard Cabot, in the first decade of the twentieth century saw the need for people
who would act alongside and in teamwork with the physicians to bridge the gap between
SAmong the photos of Richard Avedon (1993) are pictures of the mentally ill in Southeastern Louisiana
Mental Institution in 1967. These photos document that even that recently warehousing and neglect were
found in some of the large mental ho spitals.
the world of medical practitioners and their impoverished patients (Kane 1983). At first
many of these were nurses, but in 1913 social workers were distinguished from doctors
and nurses as those whose field of study was character, human relationships, and
community life. In addition to joining hospital staff, other settings soon began seeing
social workers as staff members, such as mental health clinics, schools, juvenile courts
Social workers developed organizationally, first as The American Society of
Hospital Social Workers, founded in 1918, then in a number of other affiliations
including the omnibus National Association of Social Workers (NASW) in 1955.
Educationally, stipends were first awarded for the study of social work by the National
Institute of Mental Health in 1947.
Although the growth and development of psychoanalysis and social work into
increasingly powerful and independent organizations proceeded from the late nineteenth
and throughout the twentieth centuries, these developments by no means provided a fatal
blow to the medical model for mental health. Indeed, the medical model has become
reinvigorated with advances in drug therapy. Psychopharmacology has become a major
form of treatment. Further, the Diagnostic Statistical Manuals have provided fixed
symptomology for diagnosis, recent advances in brain area mapping have provided new
possibilities for treatment, and recent advances in genetics have raised new questions
about health in all realms of the body, emotions, and cognitive health. Additionally,
recent advances in genetics and brain imaging are only two of the promising areas for
medical interventions in mental health.
Variety of Therapies: The 20th Century
All in all, there are at least two hundred therapies and numerous
pseudotherapies available in contemporary Westemn society, all intended to
counteract psychological stress and behavioral abnormality. (Cockerham
By the twentieth century, despite the fact that a large number of therapists were
still receiving training in Europe, there was a different motivation for treatment in the two
continents. Europeans were more concerned with how to control their populations while
Americans were more concerned with how to increase economic productivity (Cushman
1992). Building character "through self-discipline, thrift, hard work, cleanliness and
religious instruction" became the European model for mental health while in America the
"multilayered relationship between politics and 'personal growth'" led to stresses on
personality, "the sum of personal qualities that caused one to be liked by others .. to
stand out in a crowd" (Cushman 1992, 35).
At the tumn of the century and concurrent with Freud's development of
psychoanalytic theory and the importance of confession and suggestion, Emil Kraepelin
was developing the classification system for mental illness that is still in use. From his
clinical observations he developed a threefold classification (dementia praecox, paranoia,
and manic-depressive psychosis) that is the symptomatic system that (with some
refinements and changes in terminology) still occupies much of the thought, practice, and
theory of therapists today.
The demise of spiritualism and occult phenomena was reported after the 1904 first
Congress of Experimental Psychology in Germany. It had been replaced by a scientific
approach emphasizing observed facts and explanatory theories (Street 1994). At the 1904
St. Louis World's Fair, mental health was represented with papers by psychologists on
the current state and future prospects of psychology, followed by section meetings on
General Psychology which concerned experimental, comparative, and abnormal
psychology (Street 1994).
The "new psychology" of the 1920s, psychoanalysis, had direct effects on
American life. This new psychology "represented a revolt" against the academic
psychology with phases of psychoanalysis, emphasis on endocrine glands, and, later,
behaviorism (Bumham 1988). In London at the Tavistock Clinic, psychoanalytic therapy
for indigent clients received its first client and went on to become known for work in
psychosomatic medicine, social psychiatry, and child and family therapy (Street 1994).
During the first quarter of the 20th century, psychology was staking its own
domain in the field of mental health. Its development has been examined by Napoli:
More and more, clinical psychologists found themselves in competition
with psychiatrists, poorly trained testers, and complete charlatans. .. To
win public support they were impelled to 1) stake a claim to exclusive
competence and 2) show their service had widespread application. ..
Contrasting themselves to this source of competition, applied psychology
proudly cited their own use of the scientific method, laboratory
experimentation, and statistical techniques. .. [Applied psychology's]
realm of inquiry .. was variously seen as behavior, habits, motives,
feelings, or some combination of these (30 & 31). Applied psychologists
insisted that hostile emotions and behavior were not directly produced by
the environment but grew from within the individual as a result of faulty
patterns of adjustment (39-41). Psychiatrists .. were in no position to
treat all of America's behavior problems. Their numbers were small, their
training spotty, and their view of the situation myopic. (Napoli 1981, 53)
Psychiatry was confronted with industrial psychologists and industrial sociologists
in the 1930s and to maintain its dominance in the field of mental health in the cities
changes were made. The importance of therapeutic teamwork became evident. Napoli
holds that therapeutic teamwork was case oriented:
The concept of therapeutic teamwork .. grew from the belief that every
case required a three-pronged approach. Ideally, the team captain, the
psychiatrist, provided psychotherapeutic treatment; the clinical
psychologist administered tests; and the social workers developed case
histories. In practice, however, the duties of the psychiatrist began to
merge. It became increasingly difficult to distinguish between treatment
and case history, in part because psychoanalytic psychiatry had an
intrinsically historical method and in part because social work was
adopting psychiatric theory as the conceptual foundation for its own
professional aspirations. (Napoli 1981, 54-5)
Freud did not live to see how psychoanalysis came to dominate the mental health
scene and became professionalized.
Psychoanalysis was transformed in the years from 1917 to 1940, from the
calling of a self-chosen group of avant-garde psychiatrists and neurologists
to a profession with its own institutions for training and certification,
separate from medicine and psychiatry, yet with close ties to both. The
American insistence on medical training came in part from the wish to
attain the scientific authority associated with the medical profession. ..
Psychoanalysis enjoyed an enormous, new, optimistic vogue, vastly
expanding its therapeutic domain and its influence in medical schools and
in the newly founded National Institute of Mental Health. (Hale 1995,
Psychiatrists still headed most mental hospitals but criticisms of the historical,
clinical and philosophical grounds of psychoanalytic theory opened the door for non-
medical treatments (Hale 1995). The alienating freedoms of the industrial age had
progressed in the U.S., bringing with them "moral illiteracy, confusion, isolation,
loneliness, and self-preoccupation, leading to the need for the social practice of
psychotherapy" (Cushman 1992).
During and right after the war, there was a shuffling of accepted theories on
treatments. Inroads were made by psychologists during this period into the professional
dominance of the psychiatrists and neurologists. Medical treatment still had other
avenues for approaching mental health. In 1940, successful use of insulin shock therapy
was introduced for patients with severe mental illness (Street 1994). In 1947 psychiatrists
in Maryland announced that prefrontal lobotomy had led to the release of several patients
who had previously been diagnosed as incurable. This practice became widespread in the
1940s, but in 1950 one of the foremost practitioners, Walter Freemen, announced that he
would no longer perform lobotomies or topectomies because of their harmful aftereffects
(Street 1994). Thereafter, these procedures lost more and more favor, and were replaced
by electroshock therapy and psychopharmaceuticals, which are used today to the same
purpose for similar patients in some hospitals. Use of insulin shock, electroshock, and
lobotomies and topectomies wes reduced as drug therapies assumed ascendancy in these
severe cases of mental illness. In 1953 and 1954, Thorazine (chlorpromazine) and
Serpasil (reserpine) were approved by the U.S. Food and Drug Administration for use as
having led to remarkable progress in schizophrenics (bipolar) and some other psychotics.
The results were indeed remarkable--for a time. The problems that dopamine and
serotonin blockers have caused children and some other patients (see Whitaker 2002) is
currently being addressed by researchers, journalists, and even Congressional committees
against a well-financed pharmaceutical industry.
While psychiatrists were the primary purveyors of mental health at the start of
World War II, psychologists and social workers filled need for personnel and contributed
a non-medical, psychotherapeutic professionalism to the mental health institution. This
need led the war psychiatrists to abandon "their claim to exclusive rights in this field,
falling back to the position that they must only have overall supervision of psychiatric
patients" (Napoli 1981, 143). Behavior modification, derived from psychology's
experimentally established understanding of learning factors, became the arena of appeal
during the war years. Carl Rogers' humanistic psychology, featuring group therapy and
nondirective "insight therapy," provided a non-Freudian approach to psychotherapy
(Napoli 1981). Psychologists became even more influential when a psychological board
was created by President Truman to deal with propaganda and economic and political
activities during the Cold War (Street 1994). During these years, psychiatrists were not
the only therapists to engage in treatments which became labeled deviant. For example,
in 1951 a Seattle psychologist was convicted because he used sexual intercourse
ostensibly to cure the guilt complexes of three of his female clients (Street 1994).
In 1955 a federal commission reported that over half of the 1.5 million hospital
beds in the U.S. were used to care for people with mental illness, and declared that mental
illness was the greatest single health problem in the United States (Street 1994).
Alternatives were sought and patients were increasingly released into their communities.
"The mental hospitals released most of their patients from 1965 to 1975, and many closed
for good" (Hobson & Leonard 2001, 39). Psychoanalysis was still a potent force in
mental health and illness. In 1956 an American critic noted that more people used
psychoanalysis as an explanation of human behavior than anything else in modern times,
except the great religions (Kazin 1956). Nevertheless its dominance was waning and in
1979 it became but one of the divisions (Division 39) of the American Psychiatric
Between 1960 and 1985 nearly all the factors that had contributed to the
rise of psychoanalytic psychiatry were in part reversed: doubts grew about
the scientific validity and effectiveness of psychoanalysis; alternatives to
the psychoanalytic psychodynamic style arose; psychoanalysis lost its
identification with psychiatric reform; social conditions for psychoanalytic
practice changed; partly because of a lack of demonstrable results,
government and private funding for psychoanalytic training and research
dwindled; some psychoanalysts retreated from the new therapeutic fields
they had staked out, among them, psychosomatic medicine and the
treatment of schizophrenia. (Hale 1995, 300)
By the mid-1960s, the medical model of health and psychoanalysis was being
questioned on many fronts. Leading the attack were R.. D. Laing, Thomas Szasz, and
Emest Becker. Becker (1964, 3) insightfully argued that there was a revolution in
psychiatry due to the invasion of philosophy and the social sciences into the realm of
mental health and illness, formerly dominated by the medical view of human ills. He
argues that "mental illnesses" are "broadly culturally behavioral, rather than narrowly
medical, phenomenon." Psychoanalysts failed to make plain that the world of external
objects has to be "created" as well. Becker proposed a transactional system rather than a
completely medical or psychoanalytic one.
Increasingly, mental health professions moved toward eclectic approaches
beginning in the mid-1960s. Eclecticism emphasized "the idea that methods originating
in different schools of therapy may be combined for maximal therapeutic effectiveness"
(Amkoff & Glass 1992, 671). It signaled an openness to change.
Not surprisingly, additional therapies were developed. For example,
cognitive-behavioral therapy came of age in 1970s. It is based on establishing warm and
supportive relationships where logic, rules of evidence, and Socratic questioning (to
encourage patient to reveal, question, and correct the assumptions responsible for his/her
bleak outlook and that usually takes six to twenty weekly visits). It is preferred over drug
therapy by many therapists for dealing with mild to moderate cases of depression
(Hobson & Leonard 2001, 165-6).
The need to develop effective interventions grew in part out of an expanding need
for mental health services. Between 1970 and 1995 Horwitz (2002) estimates that each
year about 15% of the adult population of the United States sought some type of
professional treatment. Correspondingly, the number of mental health professionals
quadrupled during that time frame to meet this demand (see Center for Mental Health
Services 1996 and 1998 cited in Horwitz 2002, 4).
Education and training in therapy also changed. In 1968 the first program that
replaced the dissertation with further practical training led to a new doctor of psychology
degree (PsyD) (Napoli 1981). In 1973 this program was accredited by the American
Psychological Association as an alternative to the traditional doctorate (Napoli 1981).
"Although the PsyD program at the University of Illinois has since been discontinued, the
[Illinois program carried the force of a respected faculty in a prestigious university, a
rigorous curriculum, and an appearance of solidity that paved the way for other programs
to follow" (Paterson 1992, 836). Dissatisfaction with professional training as conducted
in traditional PhD programs continued to deepen, however, and insistence on change was
expressed in many ways. At the same time, the public need for psychological services
continued to grow (Paterson 1992). Medical dominance outside the hospital and the
dominance of psychoanalysis as the major form of diagnosis and treatment were being
challenged by psychologists and social workers especially dating from the early 1960s.
Psychologists and social workers took on new mental health roles, some of which had
previously been performed by medical personnel, after the Community Mental Health Act
of 1963. (Abbott 1988, 121).
Although the medical profession's hegemony is being challenged, it continues
especially in some areas. Not until 1974 did the first psychologists become trained and
authorized to prescribe psychoactive drugs (Street 1994). Several state psychological
associations have been instrumental in bringing to their legislators the question of
whether specially trained psychologists should be allowed to prescribe medicine.
The lessons from history indicate that therapy will continue to evolve. In the
1700s, structural factors led to a revolution in how therapy was done and who was doing
it [as noted by Foucault (1961/1965; 1973/1994) and Street (1994)]. Ideology of The
Enlightenment led to humane treatment of the 1800s (Gallagher 1980; Cushman 1992;
and Street 1994) and around the turn of the 20th century to dynamic psychiatry and
psychoanalysis (Ackerknecht 1955; Abbott 1988; Burnham 1988; Cockerham 1992;
Cushman 1992; Marmer 1994; Street 1994; Showalter 1997; and Horwitz 2002). The
rise of technology and industry for World War II culminating in the need for
psychological input led to the emergence of psychology as a major factor in mental health
and illness in the U.S. (Napoli 1981; Cushman 1992; Street 1994; and Hale 1995).
Changes in philosophy and social sciences of the 1960s and 1970s led to behaviorism,
eclecticism, ascendancy of applied psychology in mental health, and to the further decline
of medical and psychoanalytic dominance (Becker 1964).
How therapy is done continues to evolve. Recent controversies over repression
and regression therapy, especially those involving childhood sexual abuse may effect that
evolution. Labeling some practices of therapy and some therapists as deviant poses a
challenged that therapists and their professional organizations must manage. The
interviews conducted for this research are designed to shed light on how therapists are
managing that challenge.
The symbolic interactionist roots of labeling theory (Akers & Sellers 2004)
sensitize us to the prospect that deviance standards are negotiated. The labeling
perspective shares with conflict accounts the premise that more powerful individuals and
groups have more influence on those negotiations. Therapists are not powerless, so we
might expect them to influence how therapy and mental health are defined by lay
individuals. Therapists' own internal debates and conflicts will affect the negotiated
The methods therapists use and advocate provide an instrumental and evolving
infrastructure for lay understanding of mental health. As the major resource for
knowledge about the latest theories and methods regarding mental health issues,
therapists have attained high status in American society. They are consulted by
individuals and organizations for guidance in attaining satisfaction and productive
achievement in individual daily life.
Besides direct methods such as openly publicizing emerging mental health
theories and stratagems,3 therapists also provide an indirect influence. Through their
SSection 5 of the American Medical Association "Principles of Medical Ethics" directs psychiatrists (and
other doctors) to "continue to study, apply, and advance scientific knowledge (and) make relevant
information available to patients, colleagues, and the public .." (The Principles of Medical Ethics With
Annotations E specially Applicable to Psychiatry, 2001ledition, http://222 .psych.org/ap amembers/ethics
The preamble of the American Psychological Association Ethics Code states that psychologists "strive to
help the public in developing informed judgments and choices concerning behavior. In doing so, they
perform many roles, such as researcher, educator, diagnostician, therapist, supervisor, consultant,
administrator, social interventionist, and expert witness." (American Psychological Association, 2001,
http ://www.ap a.org/ethic s/co de20 0 2.html ).
research and experiences with a number of clients or patients, therapists discover and use
standards and coping methods for understanding what mental health is and how it can be
attained or kept. These standards and methods are assessed by the general public
according to how helpful they are perceived to be for clients or patients. When the results
lead to a better life for the clients, they are copied and used by other members of society.
Those who may have no personal contact with therapists are thus also influenced by these
standards and methods. Mental and emotional weltanschauungs4 and methods for
attaining mental health goals are shaped in accordance with these theories and these
Controversies surrounding the repression of memories and regression therapy
among therapists, their professional association, and outsiders (the public and law) create
confusion. Deviance will be negotiated and defined within this confusion. This analysis
now turns to the debate about repression and regression.
W eltanschauung: one's philosophy or conception of the universe and of life (Webster's Dictionary 1976).
The debate over repressed memories and regression therapy techniques to recover
those memories provide a point of entry for examining how deviance in therapy is
constructed. The use of regression techniques to recover memories of childhood sexual
abuse is especially controversial. Articles in journals from many social science
disciplines have not only challenged or defended the techniques used to discover
repressed memories, but have also questioned whether repression itself is a valid concept
to be used in therapy (Loftus 1993; Byrd 1994; Gleaves 1994; Gold, Hughes, &
Hohnecker 1994; Olio 1994; Nelson & Simpson 1994; Goldzband 1995). Some social
scientists note that there is considerable evidence that what many people think are
memories are in fact images of events that never took place. They are false memories.
There is no corresponding empirical evidence that the phenomenon called "repression"
has any reality at all (Holmes 1991; Ofshe & Watters 1993; and Pope & Hudson 1996).
Some have criticized resultant lawsuits alleging sexual abuse based on recalled memories
since no experiments have demonstrated conclusively that memories can be repressed and
then reliably recovered (Lannings 1989; Holmes 1991; Ofshe 1992; Loftus & Rosenwald
1993; and Wright 1994).
My literature review disclosed conceptual differences as to which therapy
practices are considered deviant and confronted questions about which therapists will be
labeled as deviant within different therapy disciplines. This dissertation uses interviews
of recently certified or licensed therapists (since 1995, since responsibility to third parties
was ruled in 1994) to examine the construction of deviance about therapy practices and
Freud's Understanding of Repression
Sigmund Freud introduced the term "repression." There has been an ongoing
controversy over Sigmund Freud's understanding of repression. He supplied the first
seed of controversy in 1893 when he wrote on repression "It was a question of things that
the patient wished to forget, and therefore intentionally repressed from his conscious
thought and inhibited and suppressed" (Breuer and Freud 1893/1961, 10).
As written, this passage does not imply that repression is an unconscious mental
process. However, the passage became critical in later years due to a footnote written by
Anna Freud. In the footnote to the passage Anna Freud wrote that "the word
'intentionally' merely indicates the existence of a motive and carries no implication of
conscious intention" (Breuer and Freud 1893/1961, 10).
Today, the distinction between conscious and unconscious removal of memory
from the client's access (repression versus suppression) is of great importance. In the
legal realm, tolling a tort (i.e., determining the length of time remaining before legal
remedy can no longer be sought) is governed by the legal distinction between repressed
memories and suppressed memories (memories which have been blocked from recall as
opposed to those which the individual decides not to remember but has the ability to
Present State of the Debate
Writing in favor of the concept of repression, psychoanalyst David Calof (1993),
describes his child abuse clients as having dissociative symptoms such as sleepwalking
and memory disturbances and signs of post-traumatic stress, such as flashbacks, sleeping
disturbances and nightmares and depression or other mood disturbances. These are but a
few of the many symptoms that have been attributed to consequences of repressed
memories of CSA (childhood sexual abuse) (e.g., Bass & Davis 1988; Blume 1991;
Fredrickson 1992; and Whitfield 1995).
On the other hand, David Holmes reviewed 60 years of attempts at proving the
existence of repression. He notes:
Not only do these findings fail to provide support for the concept of
repression, but they are the opposite to what would be predicted on the
basis of repression. .. Even if repression does function in the way that
therapists who work with recovered memory suppose, is it possible to
repress repeated, long-term abuses, some of which began in infancy and
lasted well into adult years? .. Of course, without the concept of
repression, the edifice ofpsychoanalysis collapses. (Holmes 1991)
Post traumatic stress syndrome is often cited as a cause of repressed memories.
There are a number of articles in rebuttal. For example, Skow specifies that there were
thousands of Holocaust victims who remembered their stress in great detail. There are
only a few very vocal orators who make the campus circuit claiming they do not
remember (Skow 1994). Rape victims also do not repress everything. Ofshe noted that
with combat and savage rapes there is traumatic amnesia but notes that sufferers know
they have suffered the experience, but have lost the details (Ofshe 1992). Paul McHugh,
director of Department of Psychiatry and Behavioral Science at Johns Hopkins
University, observed (in Wright 1994) that rather than memories being blocked out in
cases of severe trauma, children remember them all too well.
A number of individuals who "discovered" repression of memory(ies) of CSA
have later averred that their memories were not of actual events but were a product of
therapy sessions. One survey found 22% of 630 children in cases of alleged sexual abuse
later recanted (Sorensen and Snow 1991). Whatever the reasons for this change in belief,
the presence of such a number of retractors provides support to the argument that, at the
very least, some previously, strongly believed memories of CSA are false, including those
which may be a result of deviant therapy practices (violating the ethical directive to
therapists to "above all, do no harm").
Interactive relationships, social structures, and developmental socialization are
essential elements for understanding the analysis of memories--as repressed, forgotten,
delayed, deferred, manufactured, or just false--as well as for understanding how these
concepts are constructed by therapists. In view of the increased salience of repressed
memories in discourses about therapies and the polemic over usage and validity for
therapy, this dissertation is relevant as a sociological study on the construction of
regression therapies, practices within therapy disciplines, and deviance within therapy
Construction of a New Self
Debilitating mental symptoms that persist into adulthood have been linked to
childhood sexual abuse by numerous researchers since Freud initially used the concept of
repression. The role of the therapist is to assist in the processes of deconstruction and
reconstruction rather than producing a template to match the therapist's own ideology and
experiences. Through the interaction of client and therapist, memories of childhood
physical or emotional stress or trauma are discovered. Treatment incorporates these
findings. When the memory "discovered" is one that the client may have forgotten,
perhaps for many years, emergence during therapy engenders the question of the extent to
which the memory was of actual occurrences or was produced or altered in the therapy
Contexts of Therapy-Assisted Self Construction
Correlations between a number of adult symptoms and CSA have been
statistically examined by numerous social scientists. Regression theorists may suspect
and actively probe for repressed memories in clients with any symptom that shows such a
correlation (see Pope & Hudson 1996; Weene 1993; Pope & Hudson 1992; Rorty, Yager,
& Rossoto 1994; Kinzl, Traweger, Guenther, & Biebl 1994; Wooley 1994; Bordo 1993;
and Young 1993). For example, in some studies a high percentage of clients who have
bulimia also report having been sexually abused when a child. When a client admits
bulimia or exhibits symptoms of bulimia to a therapist, the therapist may suspect sexual
abuse of the client when a child and actively pursue whether this client was also so
abused. Such a therapist would suspect that the memory of that abuse may be repressed
even if not reported by the client. Among these therapists, some can and do lead the
client to a memory of an event that in actuality did not occur. They do this by techniques
promoting suggestibility which include an air of authority because of the therapists'
presumed status as "experts."
The most ardent supporters of repressed memory syndrome cite the same few
studies of bulimia and neglect to report other studies finding no or little correlation
between CSA and bulimia. Statistical correlation of symptoms such as bulimia with CSA
in such cases have been treated as causal. The therapist then participates with the client
from an initially questionable perspective in determining new adaptive ideologies,
attitudes, and behaviors to alleviate or eradicate the present maladaptive symptoms.
Therapists who discover memories of CSA suggest that a client's previous failure
to address his or her troubles resulted from memory repression that was due to the stress
or trauma of the abuse. Repressed memories may thus be seen as similar to a virus in the
mind. It infects the life of the client and multiplies adverse effects throughout the life
course into any of several mental or emotional symptoms of dysfunctionality. Using
symptoms as indicators of CSA, these therapists rigorously probe for repression. In doing
this, sometimes inapplicable group statistical data are applied to individual
clients--finding that statistical support that large numbers of adults with a particular
symptom were also sexually abused as children and then asserting that this means that
individual clients who exhibit that symptom were also abused.
Some memories that were allegedly repressed were in fact manufactured during
therapy and are false memories. Evidence of this can be found in the following ways:
Some clients have later recanted the alleged repression and fixed responsibility for their
earlier claim of recovered memory on their suggestibility. That the memory was indeed
manufactured rather than of an actual occurrence has been discovered in some of the
following ways: 1) from data provided by family members who document the
impossibility of an abuse occurring in the living time and context of the alleged abuse
(e.g., when the alleged perpetrator was not present during that time period or
circumstances of household life precluded such an act or acts from being undiscovered);
2) from medical examinations during the targeted time; 3) through court rulings; and 4)
from the demonstrable effects of certain discovery and treatment techniques and
procedures that increase suggestibility of the client to the point that there is little
likelihood that such a memory could be unaffected (e.g., hypnosis, drug therapies,
directed imagery, etc.).
Reactions to the Repression Debate
Pivotal cases which have led to legally instigated change in therapy grew out of
controversies over repressed memory of childhood sexual abuse. The type of therapy that
has been central in the elicitation of memories is regression therapy and the practices
which it often entails. I look at two major areas in this debate: The possibility of harm
and the centrality of the controversy over regression therapy.
Possibility of harm
Situations we define as real become real in their consequences. (W. I.
The pivotal axis of contention about regression therapy has to do with the
question of whether a client's images of childhood sexual abuse are accurate memories or
inaccurate artifacts of therapy practices. Regardless of which, the images can be real in
their consequences for the client and possibly others as well, especially if he/she is
encouraged to resolve the memory by confronting an alleged perpetrator. In many
instances effects do not stop with the mental health of the client; consequences for alleged
perpetrators are dire. They are so even if the images are merely images and not actual
For many therapists the strength of the beliefs of clients is a potent tool for
motivating changes in behavior, emotion, and rationality, whatever the validity of that
particular belief might be. However, over-reliance on this tool has sometimes resulted in
neglect of treatment based on the reality of present contexts. The client's state ofbeliefin
the actuality of past events can result in harmful consequences for themselves and others.
Therapists may violate the therapeutic ethical principle of doing no harm by reinforcing
and directing treatment toward an occurrence that did not happen, at least not outside of
the client's own misconception.
Centrality of the repression polemic
The dissertation explores orientations to therapy practice in three therapy
disciplines to learn how the disciplines deal with repressed memories--a concept that is
itself controversial.' The concept of "repression" as used in this research involves the
following characteristics: 1) a/some traumatic or negative events occurred to the person
in childhood, 2) memory of that/those events is blocked from recovery by normal
memory processes, 3) the memory affects the person's present behavior, and 4) the way to
cure or ease the effects of the memory is to make the event conscious and to confront it in
Some major symptoms of distress or mental illness from these unresolved
memories are called "dissociative disorders." Dissociative disorders are defined as a
class of disorders in which people lose contact with portions of their consciousness or
memory, resulting in disruptions of their sense of identity.
SSigmund Freud introduced the concept of repression of memories. His changing conception of it and the
debate that followed is detailed in Chapter 3.
For over 80 years therapists of different theoretical paradigms have argued about
the concept of repression and methods of elicitation. The recent expansion of the
controversy is manifested by the spiraling increase in the number of articles covering
regression therapy and childhood sexual abuse (CSA) that can be found in professional
journals which are dedicated to therapy disciplines. Professional ethics have been
reexamined in reaction to this academic outpouring.
The legal profession has also reacted to this controversy over regression therapy
and child abuse. In the last few decades there has been a large increase in legal cases
involving the terms "child abuse" and "repression of memory." Those legal issues were
reviewed in the previous chapter.
Consequences for Therapists and Clients
The question of whether repressed memories actually exist haunts regression
therapy. Finding that memories used for therapy were false memories, which were
recovered or manufactured during therapy, would open the therapist to charges of deviant
practice and would construct the new self of the client around a falsehood, a weak base at
A theoretical argument could be advanced that partially accounts for the recovery
of false memories during therapy. The repressed memory of CSA (no recollection) as
opposed to one that has been suppressed (recollection that is put aside) is functional for
both the therapist and the client. First, potential gains for the therapist are examined, and
then gains for the client.
Finding repressed memories increases the control of the therapist. The client may
have come to therapy seeking advice or instruction on life techniques that they he or she
is not using, is using inefficiently, or is unaware of (i.e., methods for self-efficacy). By
focusing on a "repressed" memory, the locus of power shifts to the therapist. The client
becomes dependent on the therapist who revealed this hidden property--the memory
which is beyond the scope of self-efficacy-as the root, base, and infrastructure on which
all their problems and inadequacies can be rationalized and confronted.
Psychotherapists, particularly psychoanalysts, are taught to encourage
uninterrupted narratives, removing themselves to the background, (Holstein & Gubrium,
2000). Even in encouraging these uninterrupted narratives, common therapy elicitation
techniques (e.g., silences and turn passing) can reinforce dependence and act to disallow
the client's own perception. If the therapist is passing his/her turn with a silence, the
client may come to feel that he/she has not seen or conveyed all that is necessary the topic
and may be drawn to confabulate, or search for links that do not convey what he/she had
been trying to convey, until the therapist takes his/her turn. Dependence on the
therapist's reconstruction of accepted conversational tactics comes to dominate. The
client is likely impelled to trust that there is more to be discovered.
Whatever the therapist's intentions in using these methods, the therapist becomes
essential and preeminent in the quest for change. This perpetuates dependence on the
therapist. It is therefore in the self-interest of the therapist to find repression. Regression
therapy not only keeps discovery of self focused on a particular problem--it also serves
to keep the client dependent and in therapy for many sessions.
Therapy may necessitate a protracted period for the therapist to assimilate
information and assist the client in organizing thoughts and emotions. The therapist's
personal approach to therapy influences the content of sessions through choices of which
narratives to encourage. Only through a number of sessions does the client become aware
of the proclivities and understandings of his/her therapist and assimilate them in a joint
construction of the client-self. Multiple sessions are thus required.
However, if the memory has been suppressed by the client, this process is less
efficient for the therapist. The client retains a greater degree of control and self-
actualization. Since the memory has been available for the client to recall when the
situation feels right, safe, and/or comfortable, the therapist performs a different role--an
adjunct role. In this situation the therapist is a resource for the client's decisions about
where his/her life should go rather than a component that is absolutely necessary for
personal improvement. The therapist can provide the nonthreatening, comfortable
atmosphere that the client requires to decide that it is time to confront the suppressed
memories; however the therapist is not the source of a recovery of the memory to
While finding repression increases client dependence on the therapist, the client
gains in two ways. The first gain for the client is that the repressed memory provides a
convenient scapegoat for anything not going right in life. If the memory has been
unretrievable, persons and processes other than the individual can be held to blame. Any
possible lack of self-accountability may thus be rationalized. A new starting point thus
emerges that excuses the client from responsibility for previous failed interactions and
perceived failures of his or her own self construction processes. This excuses interaction
failures and emotional and mental failures dating from the time that the memory first
became inaccessible (when the incidents occurred).
The more mundane gain is found in the legal requirement for tolling the statute of
limitations' for discovery of CSA. When the client has suppressed the memory and is
only bringing it out when in a "safe" atmosphere for recall and for confrontation, the
alleged perpetrator can be held legally accountable, in most state tort courts, for three
years after the client reaches majority (tolled after the client reaches majority, not from
the time of the incident (Hagen 1991). However, if the memory has been repressed, the
accountability is not tolled until the client "discovers" the memory or can reasonably be
expected to have discovered it, whatever his/her age at that time (Hagen 1991, and
Labeling and Imputing Victimization
On the basis of a literature review, this section of the dissertation reveals
problematic aspects of constructions of selves generated during the debate on CSA and
repressed memories. Experiencing sexual abuse has been deemed a severe psychic
trauma (Olio & Cornell 1993). Regression therapists and researchers report that sexual
abuse causes an emotional shock to the child's psyche, effacing sexual mores and causing
severe suffering (Ashton 1995; Blume 1991; Breire 1990; Herman 1992; Kihlstrom 1996;
& Terr 1994).
2 Black 's Law Dictionary defines tolling the statute as a law that interrupts the running of
a statute of limitations in certain situations, as when the defendant cannot be served with
process in the forum jurisdiction. The statue of limitations is defined as "A statute
establishing a time limit for suing in a civil case, based on the date when the claim
accrued (as when the injury occurred or was discovered). The purpose of such a statute is
to require diligent prosecution of known claims, thereby providing finality and
predictability in legal affairs and ensuring that claims will be resolved while evidence is
reasonably available and fresh" (Garner 1999).
According to the theory behind regression therapy, this shock in turn creates a
mental incapacity for coping with the events) of the abuse and causes the consequent
repression of the memory(ies). The abuse is deemed a necessary and sufficient cause of
the repression. Lenore Terr, a psychiatrist, writes that repressed memories of sexual
abuse and other traumatic memories insinuate themselves into the biological and
psychological life of a person and the memories themselves come to have lives and
transformations of their own (Terr 1994).
Adding to the argument over the effect of (a) trauma(s) experienced when a child
is the argument over whether the client should be considered a victim. The importance of
this argument revolves on the labeling process.
Calling someone a victim encourages others to see how the labeled person
has been harmed by forces beyond his or her control, simultaneously
establishing the 'fact' of injury and locating responsibility for the damage
outside the 'victim.' The discourse of 'victimization' is thus practically
situated social action that promotes practical definitions of everyday
circumstances. (Holstein & Miller 1990, 106)
Thus, authors of self-help books and some regression therapists have sometimes
become labelers. In regression therapy the labels, "victim" and victimizerr," locate the
"fact" of the harm and the resultant mental or emotional problems which may occur as
beyond the client's control. Asserting victimhood of the client shifts responsibility for
present problems from the client and to the alleged perpetrator who may have caused the
repression and resultant mental problems.
Proponents of therapy techniques which do not include regression therapy may be
seen by those who do as neglecting the primary (or original) cause of present problems.
Those other therapists, thus, may be charged by regression therapists of having blamed
the victim (the client) for problems that were in fact caused by others. A negative
consequence of the "victim" label is that victims are often blamed for their own
victimization (Ryan 1976). What is missed by such an analysis is that many of the other
therapists do not label the client as a victim at all, but as someone who should be
instructed and encouraged to take care of their present problems--to develop self-efficacy
and ability to fend off adversity.
Labeling a client as a victim of repressed memory(ies) strengthens client
dependence on the regression therapist. The use of the label "survivors") for those who
aver victimization from CSA becomes a linguistic device. This term is more capable of
activating emotionally charged views of the client and the accused perpetrator than would
be the case with more neutral labels. Use of the "survivor" label implies that the CSA
took place, for how could the client be a survivor if no act had taken place. In most cases,
for various reasons, the regression therapist does not seek to verify an actual act. Other
possible labels for the person averring repressed memories of CSA (i.e., the "accuser,"
"powerless," "memory impaired") are more direct in contextual description. For
example, a client could be described as an accuser who may have been abused when a
child and rendered powerless (at least until accusations are made), or he/she could be an
accuser with a malfunctioning memory. These other terms are sometimes referred to in
the literature on regression, but "survivor" is almost invariably the label chosen by those
authors who assert the validity of repressed memories of CSA.
Organizations and their agents make it their business to describe our lives
and experiences so that they can address, assess, and ameliorate the
challenges of daily living. In the process, they become sources of
experiential definition--purveyors of identity, so to speak. (Holstein &
Gubrium, 2000, 154)
During regression therapy, the life of the client becomes defined within a master
identity consisting of a particular "self from therapy"-a master status as CSA survivor.
In some cases this status becomes so compelling that the client becomes fixated in daily
life to the exclusion of other aspects of self. This master status may mitigate and interfere
with the formation of a more versatile self that responds to situated contexts and the
multiple organizational local cultures, which the client encounters in the flow of daily
living. Diversity of response possibilities may be circumscribed.
In this dissertation, distinctions held in different therapy disciplines on these
constructions of therapeutic labels of deviance are provided through analysis of
interviews with therapists. This qualitative analysis focuses in part on their takes on the
constructions of repression of memory, the importance of regression as a therapy tool, and
the discovery of repressed memories.
The research methodology is qualitative and informed by the work of Holstein and
Gubrium (1995). It uses "open interviews" and centers on active techniques rather than
highly structured questions. The active interview is "loosely directed" (29). It consists of
both subjective and objective elements. The objective element deals with what is being
volunteered and discussed. It is subjective because it affects how responses are
interpreted: "The focus and emerging data of the research project provide orientation and
framing resources for developing both the subject and his or her responses" (14-15).
The standpoint from which information is offered is continually developed
in relation to ongoing interview interaction. ... The subject becomes a
narrative resource for both the interviewer and the respondent, a guidepost
for how to ask and answer further questions. ... Challenged by the
interviewer, pointed in promising directions, and at least partially aware of
the interpretive terrain at hand, the respondent becomes a kind of
researcher in his or her own right, consulting repertoires of experience and
orientations, linking fragments into patterns, and offering 'theoretically'
coherent descriptions, accounts, and explanations. (Holstein and Gubrium
The "open interview" can be "constrained by the interviewer's topical agenda,
objectives and queries" (29). Active interviewers "may suggest orientations to, and
linkages between diverse aspects of respondents' experience, adumbrating--even
inviting-interpretations that make use of particular resources, connections, and outlooks.
Interviewers may explore incompletely articulated aspects of experience, encouraging
respondents to develop topics in ways relevant to their own experience (Holstein and
Gubrium 1995, 17).
One less reactive way to suggest topics is through the use of concept cards.
Concept cards serve as the resources, connections, and outlooks which set loose
parameters for discovering orientations. Interviewees can review concept cards and pick
those that are within their frames of reference as a means to initiate the "open
interviews." The interviewer operates within this contextual framework to help draw out
information. Since an interview is unavoidably collaborative, the interviewer attempts to
keep his/her collaborative input to a minimum by advancing queries on the concepts only
through neutral probes unless asked a direct question. Interviewees may take the
concepts in the directions they choose. The interviewer's input into that process is
limited to probing for the interviewees' meanings. "Questions, prompts, comments, and
clarifications point respondents to particular topics, inviting distinctive narrative
treatments" (Holstein and Gubrium 1995, 28).
Open, active interviews are especially useful for conducting narrative analyses.
"The challenge is to identify similarities across the moments [narratives] into an
aggregate, a summation" (Riessman 1993, 13). "The stop-and-start style of oral stories of
personal experience gets pasted together into something different" (14). "In the end, the
analyst creates a metastory about what happened by telling what the interview narratives
signify, editing and reshaping what was told, and turning it into a hybrid story .. (13).
In my study, that story is the tale of the respondent's place as a therapist
(attitudinally as well as rationally) within the context of therapy practices and in
professional circles grappling with the definition of deviance. That context includes legal
and societal constraints on the negotiation involved to determine which practices are
deviant and how the line between "good" and "bad" therapy is drawn.
This qualitative approach has implications for how to select interviewees, how to
conduct interviews, how to analyze information, how to use that information to select
additional interviewees, which topics to pursue, and how to interpret the data once it has
been gathered. "Investigators must continually modify initial hypotheses about speakers'
beliefs and goals (global coherence) and recurrent themes that unify the text (themal
coherence)" (Riessman 1993, 67). The approach has implications for assessing its utility:
We can provide information that will make it possible for others to
determine the trustworthiness of our work by a) describing how the
interpretations were produced, b) making visible what we did, c)
specifying how we accomplished successive transformations, and d)
making primary data available to other researchers ... Narrative analysis
allows for systematic study of personal experience and meaning: how
events have been constructed by active subjects. (Riessman 1993, 70)
Sunbj ects/Inte rviewees/Resp o ndents
A strategic sampling approach was used in which the size of the sample and the
kinds of information sought were guided by findings from prior interviews. The original
design called for interviews with recently licensed and/or certified therapists from the
three basic occupational/therapeutic disciplines-psychiatry, psychology, and social
work. The reason for the interviews was to explore how therapists constructed deviance.
Approaches to therapy varied greatly within disciplines, indicating that during
training the therapists were exposed to a variety of techniques. Disciplinary background
did not emerge as being related to orientations to perceived deviance or about repression
of memories or the viability of regression therapy. For a study of how deviance was
constructed, there was little benefit in locating a set number of subjects from each of the
three disciplines. The sampling goal became one of identifying a diverse group of
therapists rather than a set number of therapists from different disciplines.
Potential respondents were located through public records of the Department of
Health and state licensing boards, intemet directories (e.g., National Institute of Health at
http://www.nlm.nih. gov/medlineplus/directories .html and Medicare at
http://wwwl .medicare.gov/Physician/Search/Physician~erhap ), and library files on
commencement exercises by school and discipline. Alumni associations indicated that
they would contact individual graduates to ask if they would participate, but would not
provide a list. Departments contacted did not provide lists of contact information for
graduates. Since I was concerned about the confidentiality of interviewees, I did not use
any resource that would connect a particular potential interviewee with my study.
All respondents interviewed were adults. A demographics form contained the
question of whether or not the subject was 21 years of age or older. Chronological age of
the respondents was not of paramount importance. The time period within the education
process--at the end of formal training and while engaging in a career in counseling--was
the factor of importance rather than chronological age.
Respondents were not selected on the grounds of gender, race, or ethnicity. While
some differences in respondents have been found within the literature on methods and
interactional responses, my study was not directly concerned with who was being
interviewed, other than that they were therapists. Using the data gained from this
research, future research on this topic might include a quantitative research agenda to
determine the scope of contribution of these and/or other demographic elements to
therapy practice and the construction of deviance.
Ten therapists were interviewed. The number was determined during the
interviews based on how often the therapists provided similar information. This is called
saturation. Four had backgrounds in social work; four were psychologists (one of whom
had a background in educational counseling), and two were psychiatrists. They were
practicing in two southern states. The nature of their practices varied. Most were in
private practice but some were working within other medical organizations. Other
descriptive features will be discussed when presenting the results.
The potential respondents were first contacted with the letter reproduced in
Appendix A. Pages included with the letter were the informed consent document
(Appendix B) and an optional questionnaire to attain basic demographic data about
individual participants (Appendix C). Those contacts were followed with a phone call.
That introductory phone call followed four or five days after the letter was sent. An
example of the format of the calls is found in Appendix D.
In some ways the biggest challenge to this research stemmed from difficulties in
securing access and cooperation from potential interviewees. The challenge manifested
itself in several ways. Obtaining information on which potential interviewees could be
contacted (and how) was a difficult task, especially in regard to psychiatrists. It was
difficult to discern when some therapists received training and when they were certified
or licensed from many of the records which were consulted. One mental health counselor
did not believe that she fit the parameters because the letter of introduction referred to her
as a Doctor (she was not). She was so reluctant after that point that she was excluded. A
licensed clinical social worker stated that she did not know when she could take an hour
for the interview since she was working two jobs--at a hospital and her own private
practice--and also had two children. The psychologist whom I had thought would have
more knowledge on the areas of my research interest, due to her dissertation topic, said
she was too busy in her personal and work life to be interviewed even for just an hour.
Many of the recently trained therapists had relocated to distant sites. Their
letters were returned and they could not be contacted by phone or email. Many other
prospective interviewees would not return calls (even though an initial contact letter had
been sent to provide notice). With psychiatrists, I found that the receptionists and nurses
performed a "gatekeeping" function which disallowed contacting the psychiatrists directly
or by phone. When I personally handed a sealed letter containing the contact information
with the psychiatrist's name and asked that it be given to him, the nurse tore it open in
front of me and began reading it. With many psychiatrists, letters and phone calls were
not returned, even when I had been assured that the psychiatrist had received my letter or
notification of my phone call. I did not have this problem with the other disciplines.
Sociologically Interviewing the Interviewers of Clients
One question that had to be addressed was, "How do you get therapists to open up
to a sociologist?" Their professional function is to get others to open up to them. I
represented a different paradigm and discipline. Many therapists would be more at home
performing the role of interviewer than interviewee, and they were well-versed in the art
of interviewing and would recognize the techniques that are used to elicit information.
Therapists likely have some knowledge of the sociology as a discipline from their
out-of-discipline undergraduate courses. They do not consider deviance in the same way
as do sociologists. The interviews used communications tactics that would ensure a
common understanding of meaning. For example, use of the word "deviant" was
avoided. In sociology, "deviant" is understood to be a word that has a neutral meaning
and does not connote negative aspects.
Therapists are more often focused on dealing with deviant behavior and individual
thought processes and emotions than on grappling with larger social and legal definitions
of deviance. Their introductory sociological knowledge does not ensure that they will
appreciate this line of research. The experiences of the interviewees rests on a person-to-
person approach. This perspective brackets understanding within an individual contact
level which may have blunted realization of how a sociological approach provides an
opportunity for therapists to see themselves in relation to their work and to mental health
One challenge was to entice the therapists to step out of their chosen role--a doer
of therapy--into persons who could relate all the knowledge they had accumulated on
therapy and doing therapy. The goal was to elicit their narratives without manipulation.
Casual conversations with therapists and others raised the prospect that the
interviews would explore topics that were extremely sensitive for some. Some responses
may be emotional or be colored by emotional feelings. Techniques could be used to
reduce that kind of reaction, but the analysis would have to incorporate the prospect. For
example, probes would have to be worded carefully to avoid emotional responses and to
Features of the Interviews
Open interviews were conducted. All interviews were confidential. The
participants were told that they could skip areas of discussion or terminate the interview
at any time--information that also appeared on the informed consent for which they
signed and were given a signed exact copy. The interviews were tape recorded and lasted
at least 60 minutes. No interviewee decided to terminate the interview within that span
and several extended comments for several minutes thereafter. After the tape recordings
were transcribed, they were erased. In the transcription phase, any information that might
compromise the confidentiality of the participant was excluded. The transcripts were
recorded with pseudonyms rather than actual names. All records and data are kept
confidential and are controlled and protected by the investigator.
Concept card were used to introduce topics and to allow interviewees to select
priorities. My review of social science journals had provided me with relevant concepts
that therapists cover when discussing the present state of American therapy, especially
some that related to repression and regression. The topics on those cards consisted of
"Accountability, Backlash, Discovery, Epidemiology and Abuse, Labeling, Law and
Therapy, Mandated Reporting, Memory and Therapy, Primum Non Nocere (Above All
Do No Harm), Professional Dominance and Hegemony, Repression, Retractors,
Suggestibility, Survival groups, Survivors, Treatment practice, Symptoms, Syndromes,
Tolling the Statute of Limitations, Treatment Practices, and Victimhood." The concepts
were typed on 1 3/4" x 3" cards and laminated. Before giving the cards to the
interviewee, the deck was shuffled several times to show that they were in no particular
order. The interviewee was then told to select the five cards he or she would like to
discuss. By the end of the interview most or all of these concepts did get discussed.
When prompts were used, they were neutral and allowed the interviewee as much latitude
for direction of interpretation as possible. Some of those prompts are found in Appendix
Methods for Analyzing Data
Narrative analysis was the primary tool for analyzing the interviews. It was
supplemented by qualitative content analysis. Discourse or conversational analysis was
used after several interviews to assess whether the interviews were capturing the
information needed to analyze the construction of deviance.
Narrative analysis is used for interpreting data. Narratives are described by
Gubrium and Holstein (1997) as "accounts that offer some scheme, either implicitly or
explicitly for organizing and understanding the relation of objects and events described."
Riessman (1993) noted, "Narrative analysis--and there is no one method here--has to do
with 'how protagonists interpret things' (Bruner 1990, 51), and we can go about
systematically interpreting their interpretations." I systematically interpreted the
narratives my subjects related in their interviews by looking for elements in common with
the topics found in my literature review to be of importance for an understanding of the
labeling of some therapists and therapy practices as deviant. I also explored narratives
related to where the line was drawn between acceptable and unacceptable practices or
actions that were the basis for those labels. My rendering of the results centers on four
recurring narratives: orientations to therapy; memory, suppression, and repression;
accountability and ethics; legal issues and therapy.
Qualitative content analysis sometimes draws inferences on both the appearance
or nonappearance of attributes in messages. I used qualitative content analysis on the
data to help define the similarities and differences found on the narratives. Discourse or
conversational analysis focuses on how the interview proceeded that produced the
conversation or discourse. It attends to issues like pauses, repetitions, volume, speed,
body language, etc. This kind of analysis provides context for interpreting the narratives.
It can also be used to check to see whether the interview interaction permits the subjects'
discourse to be voiced without it being constrained by the interviewer. To make sure the
interviews were yielding the kinds of stories from the respondents which could be used
for narrative analysis, the conversations from the first two interviews were analyzed. I
found that the interviews were accessing the kind of data that I needed to perform
narrative analysis about the construction and response to deviance (see Appendix F).
Am I Getting Conversations and Narratives That I Can Use?
I transcribed the data from the first two interviews to appraise whether the
interviews were collecting relevant data for the research focus. Before the data were
collected, I had presumed that I would start by looking at the responses on the concepts,
one at a time, and compare them by disciplinary backgrounds of the interviewees (i.e.,
social workers versus psychologists versus psychiatrists). When viewing the actual data,
I realized that the concepts would have to be compared across therapists--a therapist by
therapist analysis--because each of these therapists related his/her experiences from a
unique perspective that prevailed through most of the interview. How the interviewee
responded indicated how he/she shaped the content of his/her answers about the concepts.
Each therapist in this set of interviews projected importance to certain topics to a
discernable degree, indicating that he/she was intent that I understand the nuances of
his/her point of view. That these varied from interviewee to interviewee is one of the
reasons for pursuing a qualitative approach.
The first interviewee provided a language couched in terms of moral exactitude.
The second responded with very minimal prompts in a language of competent precision.
It was clear to me that each of the interviews was a unique presentation and that an
examination of the concepts must include how they were told as well as what was told
(i.e., narrative analysis should sometimes be supplemented with conversational analysis).
Appendix F contains an example of conversational analysis drawn from my data.
The discourse analysis of the first cases also confirmed the utility of the concept
cards. The first interviewees selected three of the same concept cards: Accountability and
Ethics, Symptoms, and Treatment Practices. I had not asked them to put the concepts in
order of preference and was informed that they had not. I did not refer to the cards unless
our discourse on a topic came to an end without the topic having surfaced in the course of
the interview. This procedure allowed the conversation to flow from the initial question
on therapy into lines directed by each interviewee's interests. I first compared their
discussion of these concepts and then contrasted them in terms of therapy in general and
then as they related to the use of regression and repression.
My greatest surprise in these first interviews was that none of them recognized the
Ramona case until after I explained the Ramona case to them (to see if they were aware
of this lawsuit, but not by name). They hemmed and paused and passed speaking terms in
the conversation. They were also unfamiliar with other rulings regarding third-party law
suits. I learned that I had to approach these topics differently. Although the therapists
were not directly aware of the lawsuits, either through their training or their objectives,
they had developed stratagems that would safeguard them from that threat. These became
the point of entry for eliciting their narratives about legal issues and therapy.
ORIENTATIONS TO THERAPY AND DEVIANCE
The therapists orient to therapy in various ways. This chapter discusses
orientation to therapy in terms of the meaning of therapy for the interviewees, and what
they think about deviance in therapy. The therapists' descriptions of their own practices
and their thoughts about therapy in general are revealed and discussed. To help order the
presentation, the interview data are grouped by the type of occupational credentials.
Therapy treatment practices that are labeled "good" or "bad" were determined by
the labels that the interviewees themselves related.33 Deviance is also determined from an
examination of the contrasts in their labels of good or bad practices and therapists.
Additionally, I examined the treatment practices of my subjects to help delineate methods
that they have found to be normative for their discipline.
The subject of treatment practices would come up from the interviewee directly or
in response to a question on what they thought about them. I used the opportunity to
question about suggestibility in general and about practices that have often been linked to
suggestibility (e.g., hypnosis, drug therapy, guided imagery, and survivor groups).
SIn probing for deviance versus normative practice I had refrained from using the word "deviance" and
had used terms like "inappropriate," "non-normative," and "questionable practices." After introducing the
concept in these terms, I would use the words "bad" or "good" while making quote marks with my hands
and stressing the words so that it was clear that I was using these words as a label of convenience to
encompass this concept. None of the therapists interviewed appeared to have a problem with this device for
saving time and one even affirmed: "We're going to label it good. .. Yeah." For fluidity in reading the
rest of the text, the quotes symbolizing the stresses made in the interviews are removed.
Interviews with Licensed Clinical Social Workers
Each of the licensed clinical social workers (LCSWs) was able to provide a
personal definition of therapy after thinking for a few seconds before announcing his or
hers. This is notable in that each of the LCSWs used an interjection (i.e., "hmm," "uhm,"
"I guess .. ," or "uhh") to provide extra seconds for thought before answering.
Although they did therapy every day, these therapists expressed surprise that it had been
such a long time since he or she had thought about some of the basic components of the
institution of mental health (i.e., what therapy means, what are their feelings on some of
the concepts advanced in my questioning et al.).
With the exception of the interview of LCSW Amy, there were usually fairly
defined opinions and attitudes toward these topics. Amy's interview revealed a different
aspect of treatment practice. Amy came from the most medical vantage point. Her duties
in the teaching hospital where she worked were split between assisting doctors charged
with treating physical ailments and resident psychiatrists who were embarking on therapy
careers. Her input ranged from making sure that patients had rides home after their
hospital stay to alerting the psychiatrists when she detected problems which related to the
process of mental health. She dealt with patients before they were admitted to the
hospital, through their stay in the hospital, and to adjustment difficulties encountered
subsequent to their stay.
In talking about making rounds with medical professionals (i.e.,
doctors--including psychiatrists, psychologists, and nurses), Amy related numerous
instances in which she appeared to have the goals of a prototypical social worker as
outlined in the social workers (Working Statement 1981, 6):
1. Help people enlarge their competence and increase their problem-
2. Help people obtain resources.
3. Make organizations responsive to people.
4. Facilitate interaction between individuals and others in their
5. Influence interactions between organizations and institutions.
6. Influence social and environmental policy.
She described therapy succinctly and with some finality in terms ofhealing:
Mike Okay, you work with several different doctors. We'll get to ask
some questions about that. It'll be interesting--the psychiatrists in
particular. But, let me ask some kind of general questions. What
is therapy for you? What does therapy mean?
Amy: Hmm. To my mind, therapy is a process by which we heal old
hurts that are interfering with our present day life.
Mike: Mental and emotional?
Amy: Probably both.
As "a patient resource manager in a teaching hospital," Amy says her function and
duties are involved in "looking for discharge planning needs, for how we can deliver
more efficient service while the patient's in the hospital." Some of the ways she does this
are quite mundane (e.g., making sure the patient has somebody to pick them up on
discharge). Some are much more complex and involved interventions [e.g., dealing with
more involved services (e.g., HMOs, insurance companies, nursing homes, referrals to
outside social workers when needed etc.)]. Others deal with complex issues involving
relationships (e.g., family, friends, associates, and employers). From her vantage point,
"the client dictates the course of therapy and if something else is being uh projected onto
them, that would be in my opinion bad, practice."
There was a long pause after I asked Amy "What are good therapy practices." So
I switched my tack and asked her what good therapy would be. Her response was in
terms of effects on the patient rather than on what a good therapist does (i.e., techniques).
I guided her to therapy practices by directly asking what a therapist should not do as I
turned to the bad therapist section of the interview. She again turned the answer to
coming from the client (she later would refer to them as patients) and made good
distinctions based on basically passive actions by the therapist to finding out where the
client is and bad practices as failing to work from the client dictates. Ironically, passivity
of the therapist is seen as "good," contrasted with the peril of bad actions when actually
doing something with the patient.
Amy: We're going to label it "good," yeah. Umm that would be where
someone is able to function either .. either more effectively or
happily in their present day, because, they've been able to resolve,
issues from the past that have been blocking them.
Mike: Okay. So mostly it's taking care of problems and symptoms that a
person has now? Okay. What is bad counseling, or bad therapy?
What are practices that shouldn't be done. What shouldn't a
person who is a counselor or therapist do?
Amy: Always begin where the client is. Not where the client isn't.
Either uh that would be forcing solution or interventions that 1) the
client doesn't need, or the client doesn't want, or the timing is not
proper for the client.
Mike: So, in other words, you're kinda telling me that a good practice
would be to listen very carefully to the .
Amy: Yes. The client dictates the course of therapy and if something,
else is being uh projected onto them, that would be in my opinion
Mike: Okay, what's, totally unacceptable? What's the line? The person
that's gone over the line?
Amy: You mean at it's very worst?
Mike: In counseling and therapy, what would you say?
Amy: Where is the ..
Mike: "You can't do that(?)," or "You shouldn't do that(?)." Well .
"You can 't do that.
Amy: Well, either telling the client what his problem is before he's been
able to figure that out for himself--if it's even true.
Mike: Um hmm
Amy: Or imposing an intervention that's immoral or unethical or, not
something that the client is willing to really go along with.
Mike: What would one of those interventions be?
Amy: Umm. perhaps suggesting sex therapy for um a problem which
the therapist is like directly involved. I mean, that is the high end.
Immoral and unethical.
Mike: So basically sex with the client or
Amy: Right .. for his own good.
The use of pauses, turn passing, and insistence on extreme clarity in the questions
illustrate Amy's discomfort with the area of good and bad practices. When I asked
directly what the line between good and bad practice would be, she answered first by
reasserting her insistence that not directing the client is being good (even when it proves
to be in the right direction) and then by defining bad as forcing interventions on the client,
immoral or unethical interventions, and at last she gave having sex with the client as one
of the bad therapy practices (interventions)
The LCSW, Will, spoke of therapy as a process that gets one past obstacles from
the past which are impacting the client and preventing him/her from becoming fully alive.
Mike: Usually the first thing that I ask is kind of general: "What is
therapy?" and "What do you consider therapy to be?"
Will: Uhh. Therapy is a process by which people, examine uh past
events in their lives that may be impacting their lives now. Their
ability to function, their behaviors uh their thought processes and
their moods, uh their emotional world and uh to where they can get
some clarity, move past some things, move past these obstacles and
be more fully alive.
Will was the most independent of the LCSWs. His practice often involved third-
party referrals and one of his groups included a clinical psychologists. For the most part,
Will was an "independent contractor" and provided counseling and therapy in a very
similar manner to that revealed by my clinical psychologist interviewees.
When asked about substandard treatment practices, Will keyed on suggestibility.
He stated that he does not do hypnosis or dream therapy but had done some guided
imagery (one of the techniques that risks increasing client suggestibility) but preferred to
do conversation therapy to change cognitive makeup.
Will: The suggestibility, how you lead the questioning. I mean that's a
big thing in child, child abuse cases as well, you know. Who's
doing the interviewing. That's why they have to tape everything
now, because that the questions are leading. If you're talking
about, you know, all this hypnotherapy, and again, what are you
dealing with to start off with, you know, what is the (?)itic? If
you've got a therapist, a psychi>: you know, even a psychiatrist in
this. .. Who is> has a certain framework, is looking for certain
things. uh it's, you know, you can, you can go find anything. And
if you run up against, you know .. ? Some types of personality
disorders are there everywhere.
Will also expressed concern about the mental health of some of the people who
were being graduated from social work universities.
Will: I mean, I looked around my class at [university] and I said '50% of
these people oughtn't to be practicing social work.' Five years. ..
And I don't know if that's true or not. but there were some people
in there who, uh had to be weeded out. Very needy type of people.
I've seen it happen at [different university] where they they've had
to> where on their internships, people would stand up and say, this
person is not appropriate to do this work.
Will: You know. Straight "A" student and everything, but she's, she's
crazy as a loon.
Will at first brushed aside the question of the line between good and bad practice
as being subjective before I assured him that I understood the subjectivity of the question,
but that was what I wanted--his subjective thoughts on the topic. He then spoke of
failure to achieve positive results, therapists with agendas other than the mental health of
the client, and confidentiality before returning to not releasing the patient when the
therapy is not working.
Mike: I want to ask one question. What is the line between good practice
and bad practice? Who are they. How do we determine, bad
therapists and good therapists? Should something be done about
the bad ones.
Will: You know even that is a subjective thing. You know it's not like a
Mike: I know it's subjective, and you're the one.
Mike: I know it's subjective and I'm asking you.
Will: Uh, uh, yeah, yeah. I would think that if (snort laugh) their
patients get sicker (laughs).
Mike: If their patients get sicker, if they do harm--primum non nocere?
Will: They .. yeah. In uh man uh .
Mike: What's a bad therapist? Have you met any bad therapists?
Will: Oh yeah. They're people whose uh, Their agendas are more
important than their patients or that it's it's uh, confidentiality >
Mike: We didn't get to talk about confidentiality.
Will: > and that stuff. Uh. Well I'm more interested in the clinical kind
of things than the .. you know. I think that the confidentiality
thing, it's it's very important of course. But it's like. .. Now it's
bally to the hip of things. It's ballyhooed way beyond uh .. you
know, I mean it's it's it's it's. .. That's somehow, that's gotten to
be a poke. It's like things in hospitals. A lot of the paper work,
regs, and the things that you have to do, are all designed by people
who don't do that work. [Will then talked about administration and
unnecessary regulations before getting back to bad therapists] ..
Yeah. Cause a lot of people. I mean, you get people in here come
into therapy, and there's not going to be improvement. You know?
I mean, and you see that all the time too.
Mike: And so, you would want to get rid of them or just keep them?
Will: Yeah, just yeah, "Well this is not working."
The two other LCSWs, Betty and Larry, both related the object of therapy to be
freedom from something that the client is stuck in rather than healed from or got through
an obstacle. For them, the therapist helps to move the client out of the place where he/she
The focus of Betty' s responses did not appear to come from a particular American
perspective. This LCSW included an intercultural standpoint in understanding and
treatment of clients. She talked of therapy as an experience of growth that client and
therapist are both going through. She spoke of the therapist in the third person as if the
therapy is "out there someplace" to be discovered through the interaction of the therapist
and the client. This Oriental concept of "releasing" the self into mental health involved
an interaction of two selves--that of the therapist as well as of the client.
Mike: What do you think therapy is? What's it mean to you?
Betty: I guess. .. Therapy for me personally or for my clients or both?
Mike: What does it mean to you.
Betty: Therapy is .. its just an opportunity where two or more people get
together and umm and growth is going to happen somebody is
going to learn insightful things about themselves. You know, stuff
about themselves and umm is going to learn about things, how it
relates to them and how it makes them feel and how it makes them
be and behave in the world and what changes they want to make
and therapy helps them bring those leeriness to the forefront to help
them grow .. from whatever awareness they are learning. So that
to me is what therapy is.
Mike: And so a therapist would be .. ?
Betty: Like a change agent
Mike: A change agent?
Betty: Yeah somebody who just helps someone move forward out of
whatever's happening with them and move out of that because
they're stuck or ..
Betty jumped right from my question of what a good therapist would be to
therapist skills (communications and listening) and therapist morality and ethics (honest
and open). When I asked what a bad therapist would be, she answered, "a therapist who,
for their own growth and development uses the patient for that." After reassuring her of
confidentiality (that I would make sure that her identity as interviewee would be known
by no one but me), I asked her if she had know such a therapist. She related the
following, which amplified her position on bad therapists:
Betty: Okay, well not anyone locally but when I lived in [state] there was
one person who um dated their patient and the patient had money
and influence and all other kinds of other things. And I think it was
just purely for their own getting out there and meeting people that
they could also treat and whatever and um but, so I would say a
bad therapist is someone who dates their patients or who sleeps
with their patients or who um who talks about their patients, breaks
confidentiality um without anybody, you know, other than a mentor
or something. You know?
Betty: But there sometimes needs to be some help with a consultant or
whatever. So a bad therapist would be one who doesn't take care
of themselves and who um and who is not in good form for their
patients, who is not healthy and whose not modeling behavior that
is, that is .
Mike: What do you mean by healthy?
Betty: Umm Somebody who's not drunk at night and hung over in the
morning and can barely focus on the patient the next day.
Someone who doesn't exercise and sleep well so they're groggy
and sleepy and not thinking very well. um, You know? Someone
who just in general doesn't take good care of themselves um and so
they can't be fully present to their patient
The LCSW, Larry, stressed the importance of a religious standpoint. He described
therapy in terms being a guide in his relationship with clients.
Mike: Okay. The first thing is what is therapy for you? What does
Larry: Uhmm. Boy, I guess I'm taking normal people that have to be .
happen to be stuck in one of life's transitions and sort of providing
a safe place for them to work through that and try to get them to a
Mike: Right. Right .. there's no right (laughs) answer for me. It's your
Larry: I could talk for an hour but an hour is all you got, so. ..
Mike: Yeah. That's fine.
Larry: I guess coming from my perspective there's a lot of attachment
therein, basically, someone who can help a person become
anchored in their .. in that they are a person of value and often go
back and explore previous things or previous events where they
have not felt that. So it's .. transference is probably a key thing
in my approach to therapy.
Larry noted that he took the questions on "what is therapy" and "what makes a
good (or bad) therapist" for granted. After seeing pauses, I decided to change the order of
the question and asked about bad therapists first. Larry then answered the question as to
what a good therapist does--basically to play a supportive role. He begins his sessions
with an eight page introductory form that primarily provides questions to reveal
expectations of the client and to let the client know the psychological approach he takes
as a therapist. He related good practices to be those that provide unconditional, positive
regard to affirm the values of the client. His practice provides a secure place to explore
the gap between psychological and spiritual realms. He did this primarily through
Mike: Would it be easier to say what makes a bad therapist, an
Larry: (Inhales) I'm probably influenced a lot, by Carl Rogers on the
whole, issues of unconditional, positive regard. A therapist has to.
.. A person wants to get from where they are--to some other
state other than where they are right now, and that involves
influence and yet a realization that I don't know their world
completely. So a good therapist is somebody that affirms the value
of a person, so that that's a settled matter, and they can explore
other things that might be a little more threatening to them in any
We discussed authoritarian relationships often requested by clients and then I
returned the conversation to the topic of bad therapists. In the following section Larry
talks of a particular therapist who was involved sexually with a client.
Mike: Okay. Let's go to what's a bad therapist, what makes. .. This
kind of emotional thing. Have you known people that you
considered to be bad therapists, and what was there about them that
made them a bad therapist? And if not, what would make a person,
you would say, a bad therapist?
Larry: Most of what I get is self-reports of clients' experiences without the
without a therapist. Yeah, certainly you get into the extreme.I
have indeed conferred in a therapist that entered into a sexual
relationship with a client.
Mike: And you said .. ?
Larry: I inherited that client, so something at that extreme, uhhm. Often
it's more in the area of, probably, the use and abuse of influence,
having an agenda for how they need that person to ., what
direction they needed that person to go in. So. Ahh, they've
usually been in areas pertaining to power and areas pertaining to
He then spoke of abuse of influence and then used his early experience as a
therapist to point out the trap some therapist may fall into (letting their own emotional
needs lead them into pressuring the client to outcomes) to those which may be more for
the therapist's own benefit than that of the client. He then spoke disparagingly of
therapists who abandon the client when help is still needed.
Overview of How LCSWs Define Therapy Practices and Therapists
While I decided to ask about "the line" between good and bad therapy practices at
an early point in all the therapy interviews, I also returned to "the line" at the end of all
my interviews. In many cases, psychologists and psychiatrists as well as the social
workers added to their statements. With the exception of social worker Will, the
therapists were all asked about good and bad therapists very early in the interview. The
flow of Will's interview precluded my asking until near the end. Whether it was an
element of the process of the interview or some other factor (i.e., we had talked about
sexual abuse of children before this topic was asked about), LCSW Will was the only one
of the clinical social workers who did not mention that therapists who have sex with
clients, present or former, are bad therapists.
Each of the therapists had several persons who were resources whom he/she could
call upon for support and to help him/her maintain good treatment practices. Amy had the
medical staff at the hospital and several social workers that she called upon for
specialized service for patients. Larry met weekly with another social worker, a
psychologist, and a nutritionist. He also spoke of contacts with clerics who were one of
his resources for new clients and in at least one instance had provided counseling
assistance. Will shared an office with a psychologist (alternate day occupancy) in a clinic
which included other clinical social workers and psychologists. He also conducted a
mental health group with a psychologist at another location. Betty was supported by
other students and instructors at the clinic where she worked and where she was getting a
degree in acupuncture. She also had contact with massage therapists and other alternative
health specialists (mental as well as physical).
While my literature review had been rife with expostulations and defenses on
what traits a bad therapist has, and often these were contrasted with good therapists, I was
surprised to discover that the interviewed therapists did not have such formulated
opinions. After I discovered this in an early interview, I rephrased my question and asked
about good practices as opposed to bad ones. At that point I left open the definition of
"practices" (i.e., whether I was asking about how offices were run or what techniques
would be labeled bad or good). I was interested in both, but I wanted to find out which
ones each therapist would preference in their initial answer. Finally, when asking about
practices, I included that I was interested in finding out what was the line between
practices that were labeled good or bad. Each of the changes I made in presenting these
topics brought more immediate responses and appeared to reach areas which had more
saliency for the interviewees.
LCSW Amy did list some of her roles as a resource case manager, but only Betty
spoke of good therapists as those who had definable skills (which she enumerated) when
she talked of the necessity of maintaining professionalism [my term]. Amy strongly
stressed the importance of being aware of and following the dictates of the client in
deciding on interventions; Larry spoke of providing a supportive role; and Will said that
it is important for the therapist to help in solving the client's problems and stopping the
therapy sessions when they are no longer producing positive results.
When talking about bad therapists, all spoke of the fault of giving precedence to
the therapists own agendas and/or needs over those of the clients. Betty and Will spoke
of the importance of maintaining confidentiality. Amy's definition of bad therapy
practice was that it is the opposite of the definition of good therapy--not following the
dictates of the client/patient-therapy processes must involve and spring from the client.
For Larry, the paramount difference from statements of the others was in emphasizing the
importance of continuing the therapy support, and not abandoning the client prematurely.
While Larry advised caution in not letting the patient go too soon, Will advised caution in
not letting the patient go soon enough.
The social workers who had been interviewed were essentially trained to assist in
the practical concerns of their client/patients. To become Licensed Clinical Social
Workers they also had been required to pass a national examination. Three of the
LCSWs were occupying primary therapist roles and the other was performing roles and
tasks within a teaching hospital. These tasks involved supporting doctors charged with
physical problems and supporting the psychiatrists who were often residents assigned to
the hospital. One aspect of her support took the form of alerting medical personnel to the
mental health needs of the patient for coping with the world external to the hospital
environment as well as within it.
All of the LCSWs had support people to assist in their practice as needed. Those
in private practices performed functions described similarly to those of other primary
therapists. They acted as the primary mental health resource for their clients on a one-on-
one basis and led mental health group sessions. Each of their offices was in a clinic
which contained other therapists and available support personnel.
Two of the LCSWs oriented to therapy related that clients were mired in situations
and conceptual binds that were affecting his/her mental health. Another was concerned
with blockages restraining the client from mental health. The fourth was oriented to
treating mental illness as an injury and herself as a component of the healing process.
The LCSWs in private practices all used brief therapy consisting of only a few therapy
sessions. Each had treated clients in group therapy sessions as well as individually.
Along with Will, Amy and Betty noted that character flaws were additional
barriers to good practice. All had, in at least one instance in their careers, experienced the
actions of a licensed clinical social worker that they labeled "crazy." In each of these
cases, they were appalled that such a person could be licensed. Since this research is
concerned with the labeling of practices as deviant or normative and leaves questions of
character for others to pursue, the interviewer did not probe for details or seek other
instances of character flaws, which are not directly proscribed by professional ethics or
The LCSWs correlated bad therapy with doing harm to the client (i.e., primum
non nocere). For Amy sexual abuse of patients by the therapist, cultivating extreme
dependency on the therapist, and manipulation (even when it results in a good outcome
for the patient) were the things that harm patients. Larry discussed harm that came from
counter-transference. Will and Betty more directly related harm to not being sensitive
("present") for the client/patient. All of the social worker interviewees advocated some
kind of constraint by licensing boards although the form that this might take varied,
To get to actual therapy techniques, I had noted that my literature review had
brought up the practices of hypnosis, drug therapy, and guided imagery and, in turn, asked
what did each think about those practices. Will had used guided imagery at some times in
his practice, but he preferred to use talk. He strongly cautioned that use of these
techniques raise the issue of suggestibility and that use of them opens the therapist to
accusations of managing the client rather than helping them solve their problems. None
of the others had used any of these techniques. Betty and Amy also were concerned about
suggestibility in relation to these techniques but accepted that they were used by others.
Larry's theoretical perspective precluded use of hypnosis or guided imagery. Betty was
particularly concerned about the over-prescription of psychotropic drugs but like the rest
said that they were useful in some instances.
Interviews with Psychologists and an Educational Counselor
The clinical psychologists and the educational counselor spoke of using a
cognitive-behavioral perspective on therapy. All, however, were eclectic in their
selection of particular approaches and goals. These were tailored to the context of the
therapy sessions and the content of the social an physical environment of a particular
Rick, a psychologist, got several of his clients from referrals by clergy. He
differentiated between an ideal type of therapy and the way therapy is practiced.
Nevertheless, his theoretical perspective was very similar to the other psychologists but
focused more on fitting client selection according to his religious framework. He did not
believe that there was a conflict between his religious beliefs and his theoretical training
but did give examples of times when his religious beliefs had affected client selection. At
first, he appeared taken aback by my probe about therapy. He chose to reframe my
question "What is therapy?" into "What therapy should be?" He answered that it should
be a way of producing wanted and healthy changes in life.
Rick: In essence, therapy I believe, not to get too Clintonian, but I guess
part of the reason I'm having trouble answering your question is it
depends on what you mean by 'is.' So I'm going to answer instead,
"What therapy should be." Therapy for me should be, a, mode by
which a professional assists, someone in, producing wanted and
health changes in life[?].
When I asked how he (a therapist) does that, he discussed theoreticians from the
cognitive behavioral perspective and then a theoretician from the solution oriented
approach. In the therapeutic discipline blank on the demographic data form he had
written "'predominantly co gnitive-b ehavioral, informed by other appro aches, including
Hypnosis was a technique that Rick had used to help a client do things that the
client wanted to do but had resistance to other therapy techniques. Rick remarked that he
had some training in hypnosis and the client had suggested trying it. Rick did not find it
to be effective. He said that with more training he would consider using it in the future
for changing expectations, but not for changing personalities.
Rick: It's that 'hope' concept. "I can't stop smoking, I can't stop this,"
or "I can't get along with my wife." "Yes you can!" [laugh] You
Rick: And if that ends up being a tool that somehow, [raps on table] the
ritual and all that of it, uh tends to be more convincing than my just
saying, "Well if you try this technique .. ." Then it's something
used for positive value and a gain and service--fine!, It's a valid
therapy. Uh there's a cliche for that. But [laughs]. Uh, in that
context, I could see using it. My belief in hypnosis as being .. a
thing. Uh it was some type of, you know, quasi-magical thing that
really has a lot of effect on its own. It's limited. But I do know
that people, uh are convinced and sold on ideas of different ways,
and if hypnosis can be used in a way of, of increasing their,
expectation of change, buying into that suggestibility, sobeit. .. I
don't use it. I guess what I'm trying to maintain here and make
clear here is that I don't have an absolute prohibition against the
idea, if I thought it would be helpful to do. I just haven't found a
case where it is.
Rick did not use guided imagery about memories but he did use imagery in
relaxation techniques, "imagining themselves." He did not use pharmacology because it
was not available to him. He did see it as a tool helpful for therapy, depending how it is
used, but did not go into detail as to when it is misused.
Rick was very succinct in his statement about when a therapist has done bad
practice: "You're going too far, when, you lose track of who the therapy is suppose to be
about. It's not about you, it's about them."
When I asked Rick what makes for a good therapist, he first responded with
personal traits that a therapist should have and then working with the clients instead of
trying to.Ax them and finally respect for their values. Rick was the therapist who rejected
potential clients on the basis of his own values. Therefore part of his approach involved
his ability to show the client that he shares their values.
Rick .. [exhale]. Well certain obvious things-intelligence, uh uh
insight, understanding, study--all that kind of good stuff. Uh, but I
think the basic, uh, Respect for your clients as as a partner in the
process. Uh, you're not,Jixing them. If you view it that way,
you're going to be far too uh aggressive, and you can either .. can
push them in directions that they, they don't want to go. uh You're
kind of helping them fix themselves. so a kind of respect for them,
and uh, which includes uh, a respect for their values. Kind of goes
back to the question about, How do you build the trust. uh you
know, where possible, kind of showing you know that you share
their values. uh
Rick:: Just part of how I end up getting a lot of referrals.
Bad therapists are defined as ones who have their own agendas and "wants
everybody to fit into their mold." He thought that everyone has his/her own world
outlook and philosophy, but therapists should make theirs "up front," "so that they can
know whether they (clients) match you and find somebody else if they don't." Rick's
religious outlook and ideology were very important for him.
Rick: I don't pretend to be unbiased. uh I'm in favor of, faith and values
and strong marriages and that kind of stuff and if you want
somebody who's gonna, tell you how to get out of your marriage
without any guilt.> I can recommend you to a few other therapists.
You don't want to be working with me.
Being "up front" and selecting clients with similar values were the way Rick
avoided being a bad therapist and having his personal agenda affect his clients. "Agenda"
for Rick had three components: philosophical (melding professional and religious ethics);
financial (e.g., keeping somebody in therapy when they really don't need to be); and
emotional (e.g., inappropriate relationships). The interview flowed into the authority that
a therapists represent and the need to listen to how the clients talk about their and
problems. These are examined for logical errors and fallacies that the client is telling him
or herself and, as a therapist, Rick would focus on solutions for the client.
Rick's practice was slow at the moment. He did not accept clients from HMOs
and clients were responsible for dealing with insurance companies. He said he would
work with clients with insurance, but required them to pay up-front and collect the
insurance remuneration themselves. Since he did not collect fees from third parties, he
did not feel that he needed to spend much time on diagnosis. He would go straight to
problem solution. If a diagnosis was needed by the client for insurance purposes, Rick
would consult the DSM IV. When I asked what was the line between good and bad
therapy. He said, "good therapy is about them, bad therapy is about you."
Karen, Ph.D. in educational counseling, defined therapy in term of the privileged
responsibility of helping balance the clients' feeling and "head" aspects. She referred to
"solution focused therapy," but indicated it was an insufficient label for the type therapy
she did. In addition to focusing on problems that the client was presently having, she
added that her work was eclectic and involved helping people get balanced in their lives
by working on "the feeling side of them," not justt in their head all the time." Karen also
described therapy as a privileged position with responsibilities.
Karen: Well it's a very privileged position I have in terms of .. in terms
of people trusting me with their stories and with their issues and
their problems and concerns and helping them believe that there is
a way to live a better life, be truer to themselves, live in--I'm
trying--harmony and community better, be at more at peace with
themselves, make changes that they want in their lives.
Ethics was the key to good treatment practices for educational counselor Karen, a
Ph.D. in educational counseling. She also mentioned respecting the confidentiality of the
client to the extent legally possible. Karen talked about ethics and laws throughout the
interview and sometimes it seemed that she was waiting for me to express something to
give her a cue as to what her answer should be.
Approach to therapy and techniques were not so important to Karen as living up
to professional ethics. She felt that different approaches which might be inappropriate or
ineffective for a particular therapist might work for another. This was the moment I
chose to ask about the Ramona case (amplified in Chapter 9). I concluded a short
synopsis of the case by noting some of the practices that were discussed in the case and
noted: "They used certain practices--hypnosis, Sodium Pentothal, directed imagery and
uh a lot of things that had to do with suggestibility. Do you use any of those in your
Karen: (Laughing) Right, right. No I don't do hypnotherapy and directed
imagery. I'm not sure what you mean by the term. Let me put it
this way, is your question what do I do about repressed memories?
Mike: Yeah that, should do.
Karen: Ye(laughs)ah, uh I atypically, everything's individual. I mean that
there's not one thing I do in my life, probably, that I do in the same
way every time--not even how I brush my teeth. So, I do believe
that people can repress memories. I think it's a phenomenon, I just
accept it as such. Do I work, to pull those out of people? I don't. I
think they are .
Mike: You don't probe?
Karen: I may ask them some questions and I'll test, I'll watch reactions,
I'll listen to words, I'll, you know, watch, you know.
Mike: But you don't open it up?
Karen: Let's see do I open it up? If it's appropriate. Am l a sleuth about
them? No. No, there's a reason that they're sort of latent and I
think it can be harmful. I mean, if it's relevant I work with it, but.
After stating that she did not use any of those techniques, she assumed that I was
asking about how she approached repressed memories. She believed that people can
repress memories and believed that repressed memories can be harmful. Karen would
ask some questions about the memories if the client brought them up, but would not
probe for them. She showed some uncertainty about the relevance of these memories for
diagnosis and/or treatment by ending her statement on their relevance with a subjunctive
"if" and the open-ended qualifier "but. .."
Of all the therapists I interviewed, Karen was most guarded in her answers. As
the interview went on, she would volunteer information. In the early stage of the
interview she would use stalling tactics such as repeating the question as if she had not
heard it, laughter, and long pauses as if passing her turn to speak, even to respond to the
question. One example is that she took a comparatively extremely long time to select five
cards from the concept cards. She reacted to the cards as if they were a test. Finally she
indicated her quandary:
Karen: I know what I am going to do, just decided what I am going to do
with these. [A few words were accidently erased from the tape] .
process it and one of the things that get sorted are people with tests
like these are quick to make judgments or they think about the
possibilities forever. (Karen laughs) I know. I know, but I'm just
thinking. .. You've got someone who's gonna try to think like,
"Well if I put these, then what will that mean." Rather than "Oh
this, this, this, this."
She was also judicious in defining a good therapist. The following is an example:
Mike: Okay, what makes for a good therapist?
Karen: Well, lots of things. (laugh)
Mike: What's number one?
Karen: Yeah, what's number one?
Mike: What is the one thing you would say if that person doesn't do that
thing, then they're not a good therapist.
Karen: To be ethical.
Mike: To be ethical?
Karen: Yeah, cause I think. .. Take ten therapists with the same client.
We can approach things ten different ways and then we can all be
good or we can all be horrible. (laugh).
For Karen, following the dictates of the law and the ethics of the profession
determine if the therapist is good or bad. She indicated that she hoped that the legality
and professional ethics would be the same in a particular case, but the final determinant
of the line between good and bad practice was "the law! "
The other psychologists, Gail and Zoe, spoke from an educational perspective.
This was discernible by the text of their discussions as well as from the fact that Gail was
involved with children with problems often regarding intellectual barriers and that Zoe
was primarily involved with students at a university. Throughout their interviews, they
would demonstrate facility in the transmission of knowledge--what they knew about a
subject. This perspective is associated with the educational system more so than with one
of the other institutions.
Gail said. "I don't really feel like I have a certain orientation toward therapy."
During other elements of the interview, I would pose a question and she would give
remarkably detailed and inclusive answers that were obviously not memorized but
internalized-illustrating a firm understanding of the topics. Her answer for this question
appeared to be less formed and more in the process of being thought out as she spoke it.
This is notable in the uncharacteristically uneven flow of the answer illustrated by the
second part of this exchange:
Mike: In, your words, what is therapy? What do therapists do?
Gail: I think therapists work with people to consider situations that are
creating some sort of stress or unhappiness and explore options for
making changes, so that they can feel better.
Mike: Where do you fit in therapy?
Gail: I really, it's hard, I'm kinda eclectic. I guess that more uhm .
Sometimes ., Depending on the problem, you know .. this
depends on the problem, so like your, your typical behavioral kinds
of things .. or your anxiety kinds of things. I'm more cognitive
behavioral. If it's a relationship issue--I'm more interpersonal. If
it's more of something like, uhm your recurrent problematic
patterns, like you know, someone who's got more of a personality
disorder (which I really don't see much here now, but I use
to)-uhm I might do more of a mixive, interpersonal and insight
oriented kind of work.
From answers to this and other questions, it became apparent that for Gail therapy
is primarily what a therapist does. A therapist works with people and explores options for
making changes so that they can feel better. She had not put an answer in the blank of the
demographic form which was for Theoretical Perspective, but she described herself as
eclectic in her approach to therapy during the interview.
Good treatment practices for Gail were those which provide interventions. For
her, interventions are "suggestions" that are made for the clients and with their input.
Gail: Treatment practices would mean: what kinda interventions are
your gonna put in place, what kind of suggestions are you going to
make to parents, or things that you are going to suggest to kids or
what sorts of options are available to them for getting the needs
met. Because we are a multidisciplinary setting, I really think that
treatment practices is having a wide range of things that patients
have access to.
Mike: What types of interventions do you do or do you suggest or. ..
What do you do?
Gail: Well, a lot of times we're going to work on things that improve
communication, or things that will improve expectations, behavior
and discipline at home, and we're kind of just making some things
clear that haven't been, and helping kids to understand what's
going on that's creating behavior problems and what kinds of
incentives and consequences are available when they make
different kinds of choices. A lot of times parents are coming
because they're having a difficult time managing their
temperament and their child. So, knowing about the treatments we
have like things that they can get from censoring litter treatment
and all possible help with medication. We also talk about the
options they have and their feelings about pushing, or not.
Rather than speak of specific treatment practices or techniques, Gail related them
to the unspecified ways used for clarifying causes, incentives and consequences available
for choice about clients' problems and that are used to work on improving the clients
abilities in communication, expectations, and behavior. While she did not provide any
information on guided imagery or hypnosis, she was very much in favor of her clinic's
biomedical connection and its multi-faceted approach to the practice of therapy. She
went into detail in describing that:
Gail: This is a, you know, biochemically, medical facility, and I'm very
much in support of it. I do think, that it's uh, probably over-
prescribed at times, and I think -
Mike: Here, or .just in general
Gail: umhm, I don't think here. I think that in general. I think it has
been carelessly prescribed or I should maybe even say carelessly
monitored. I feel like, by the time a patient here, has been
prescribed medication, we've done a pretty exhaustive assessment,
and uh, we're getting information from families and parents and
our intensive zone and observations, and seeing them multiple
times and so I feel pretty confident. I also think when we prescribe
medication, we do follow-up assessment, we get teacher feedback,
we get parent feedback, and we have parents keep journals. and so
on, I think when, when we're doing it, it's a- I think sometimes
people use it as a way to treat, for instance, behavioral problems,
and while a lot of kids have behavioral problems, medication is not
gonna address them. Uhm, you need a multidisciplinary approach
and, for a lot of the kids that have the disruptive behaviors, they
need .. they need their own strategies, they need medication, they
need to leamn arousal techniques (which is a big piece that I've
learned from our occupational therapist that they provide the kids)
just learning how to modulate your own arousal level .. for
different situations, to rev yourself up or rev yourself down.
Gail: So, It's very interesting [the study of arousal techniques]. I mean,
and a lot of the kids we work with have a learning disability, have
attention difficulties that are secondary to having learning
disabilities because when you're working, when you're in an area
where you're already .. stressed, and you have to work extra hard
to keep up with everyone else, your stamina is gonna be less at the
end of the day than the other kids that didn't have to work as hard,
and that's gonna create attention problems. And so if you can, you
know, boost your system by having medication, it's gonna make
the learning easier. And I'm very much in support of that. But I
do think, sometimes, that a fifteen minute interview might be all
that a, physician needs to give someone medication.