Psychiatry 64(2) Summer 2001

146

Ethical Dilemmas, Good Intentions, and the Road to Hell: A Clinical-Ethical Perspective on Yaloms Depiction of Trotters Therapy
SIMON SHIMSHON RUBIN

FICTION in literature can assist in the analysis of therapeutic and ethical dilemmas in psychotherapy. Lying on the Couch (Harper Collins, 1997), Yaloms account of Dr. Seymour Trotter and Mrs. Belle Felinis therapeutic encounter, describes a complex series of issues and dilemmas. In the present article a reanalysis of the case from the perspective of a clinical and ethical consultation is presented. The therapeutic crisis that preceded the sexual relationship and the initial presentation of the client are considered in detail. Following the discussion of each of these periods, alternative modes of understanding and intervening in the treatment are presented. The in-depth exploration of a fictional case such as this one allows therapists to critically evaluate the decisions that underlie problems in the therapeutic encounter. The article concludes with specific recommendations for clinical and ethical practice. Seeking to benefit the client, to do good work, and to do this within the framework of acceptable ethical behavior characterizes the vast majority of health care professionals. There are times, however, when it is not easy to reconcile the demands of the profession, the needs of the client, and the adherence to standards of ethical behavior required by the profession and society. This article considers the report of a treatment gone awry and consider the choices made and opportunities missed to help the client, to do good work, and to stay within the ethical boundaries required. To advance these goals, we consider the advantages of a consultation applying a clinical-ethical perspective. To do important work, therapist and client must leave room to meet in an encounter that can unleash as well as harness powerful forces of human existence. The tempestuous course of a therapeutic encounter beset by the forces of the past and the present, of reality and fantasy, of longing and of acceptance of lifes frustration, can fray many threads of the therapy structure. In the case to be discussed, the therapist who is unprepared for the severance of that structure has failed his client and his task. Rather than pronounce judgment, it will be the goal of this article to increase the vision and the ability of therapists to remain within the parameters of their goals. The gap that exists between desired ethical behavior and actual practice in the health care professions in general and psychotherapies in particular will continue to receive attention because it is so fundamental to the human condition (Beauchamp and Childress 1994). Saying no and thou shalt not to

Simon Shimshon Rubin, PhD, is Chair, Clinical Psychology Program, and Chair, Postgraduate Psychotherapy Program, Department of Psychology, University of Haifa. The author thanks his colleagues Yael Liron and Gaby Shefler and the reviewers of this article for their suggestions. Address correspondence to Dr. Simon Shimshon Rubin, Chair, Clinical Psychology Program, Department of Psychology, University of Haifa, Haifa, Israel 31905; fax: 972-4-8240966; E-mail: [email protected].

SIMON SHIMSHON RUBIN unethical behavior is part of the education for professionals in the psychotherapies (Koocher and Keith-Spiegel 1998; Pope 1994). Teaching legal liability and studying ethics codes are important as well. Yet case analyses, where one addresses the issues about a particular instance, are helpful teaching vehicles (Furrow, Johnson, Jost, and Schwartz 1991). Case studies allow us to consider the issues, the choices, and the outcomes of particular interactions that occur in this type of situation. Fictional literary examples are perhaps no less valuable than actual case studies in that they allow us to deepen our understanding of the complexity and choice points that ethical and well-meaning practitioners may face. Irvin Yalom (1980), as an author and psychiatrist of international renown, provides us with numerous examples of material that lend themselves to ethical analysis. Analyzing a case constructed by this responsible, learned, and creative professional allows to consider issues that concern professionals. The primary vehicle for this analysis will be the consultative encounter where professionals consider how they would have consulted to the therapist in question. Having taught both young and experienced professionals about ethics in the therapeutic encounter by asking them to consider what they might have said as consultants, I refer to their responses from time to time in the following material. My own thoughts and responses to the material are liberally represented as well (Rubin 1986, 1997). The case discussed appears in the prologue to the novel Lying on the Couch (Yalom 1997) and tells the story of an ethics investigation into a treatment conducted by a Dr. Seymour Trotter.

147 of difficulties and unsuccessful treatments with numerous therapists and occasional voluntary hospitalizations. Each of the previous therapists was rejected after brief periods. Trotter undertakes treatment. Although the therapist did not secure a formal history at the time of initial contact, over time the history of the client did emerge. Mrs. Felini was a woman whose mother died at her birth. She was then raised by a series of governesses. Her father had an obsession with cleanliness and an aversion to physical contact. He was involved with a string of prostitutes and eventually married one. The first emotional breakthrough occurs after client and therapist role-play her recurrent fantasy of a child being taken care of by an older man. Throughout the treatment, the wish for actual gratification from the therapist surfaces, with Trotter indicating that a modicum of nonsexual touch was helpful to the treatment. Dr. Trotter continues to work with the client (whom he refers to throughout by her first name) in a situation of somewhat relaxed boundaries (e.g., in the area of touch). At the same time, there is strict adherence to other boundaries and the requirement that the patient be honest in reporting her life and fantasy life. What began as an interest in contact with the therapist escalates over time, and eventually results in a potential crisis. Despite significant improvement in her behavior, Mrs. Felini ultimately feels that without a degree of actual contact with Dr. Trotter, she will slip away from treatment and back to selfdestructive life-threatening behaviors. With a focus on keeping his client in treatment, Trotter eventually agrees to a 2-year wager proposed by the client. If Mrs. Felini can live up to her end of the bargain, Trotter agrees that the prize will be as she requesteda weekend together without any preconceived boundaries or therapeutic framework. Trotter agrees to this after he believes he has thoroughly considered the matter. He is convinced that the odds of this wagers being collected are close to zero and he sees this as a no-lose situation. Either his client will be unable to keep the conditions of the contract for the 2-year period agreed (thereby forfeiting the

THE CASE

The synopsis of Trotters description of his contacts with Mrs. Belle Felini is as follows: Seymour Trotter, an aging, eminent authority in the field of psychiatry and psychotherapy, is referred an attractive, extremely impulsive, intelligent, promiscuous, self-destructive patient. The client has a long history

148 ability to collect the contact with him at the end) or by keeping the contract she will become so changed a person that she will no longer be interested in collecting anyway. Despite his predictions, Mrs. Felini is both able to stick to honoring the conditions of the contract and to remain focused on wanting to collect her prize. The first 18 months, Mrs. Felini continues to show and sustain her dramatic improvement (studies, volunteer work, writing her autobiography, etc.), but for the last 6 months the therapy increasingly focuses on the upcoming weekend. Trotter enters an intense period of anxiety, and although he interprets and attempts to dissuade the client, it is all to no avail. As the time draws near for Trotter to honor his part of the bargain, and as he realizes that his patient will not voluntarily release him from their agreement, he feels himself unable to do anything but keep his side of the agreement. He is convinced the alternative is the destruction of his clients trust. Patient and therapist honor their agreement. From that point on, the treatment can no longer proceed, with dire consequences for the patient and fatal damage to the reputation and career of the elderly therapist. The follow-up is much more ambiguous, however, as Trotter and Felini are eventually reunited. This seems to work to the ostensible benefit of Trotter while the consequences for Belle Felini are unclear. A common reaction of professionals who read the case of Dr. Seymour Trotter and Mrs. Belle Felini is to understand it as a clear violation of ethical rules and boundaries. Sexual contact between therapist and client has been unequivocally discredited and ruled as unethical, harmful, and malpractice. One would be hard pressed to disagree with that assessment, yet it is difficult to believe that Yalom would trouble himself and us as readers if the case were not more complex and worthy of some degree of suspended disbelief as to the degree to which this case is indeed quite so open and shut. This is ground that Yalom has touched on before, perhaps most notably in Loves Executioner (Yalom 1989) where he addressed some of the nagging doubts that

ETHICAL DILEMMAS he and others might have about the universal negative outcome to crossing sexual boundaries. My experience teaching therapists has shown me different sides of the impact of the material. For newer persons in the field, there was initially little room for nuance in their consideration of the issues. Discussion of the case could proceed with these developing professionals, but much of it required a conscious effort for them to consider the boundary issues as anything but inviolate and Trotter as not immediately wrong. The most common responses to the chapter centered on an almost deontologic statement that boundary violations are wrong as an appropriate if often unarticulated or unspecified philosophy. Another group seemed to condemn Trotter no less but did so on pragmatic or utilitarian grounds, suggesting that the outcome was what determined for them that the boundary violation had been wrong. They based themselves on the fact that Belle Felini looked unhappy at the end of the prologue: He peered closer . . . trying to discover some clue, some definitive answer to the real fate of Seymour and Belle. The key, he thought, was to be found in Belles eyes. They seemed melancholy, even despondent (Yalom 1997, p. 33). With more senior persons, the response to the case had greater subtlety if a no less negative view of the therapist as perpetrator. Gender differences were present in the evaluation, with the women in general having a more negative view of Trotter than the men, which sometimes extended to a more negative view of Mrs. Felini as well. The implication that men are more easily sexually aroused than women, and are more likely to cross boundaries, is neither new nor inaccurate (Pope 1994; Rubin and Dror 1996). As presented, the case involves a breach of trust by the therapist to the patient, her family, the profession, and society as a whole (Brennan 1991; Gonsiorek 1995). Strictly speaking, whether or not Mrs. Felinis eyes were melancholy, and whether Dr. Trotter was pleased to be able to live with a younger woman who was willing to care for him in his physically weakening state, the case turned out badly. Whatever real

SIMON SHIMSHON RUBIN or imagined benefit may have occurred as a result of the therapy process while it was still therapy, the case as therapy clearly ended under negative circumstances (Strupp and Hadley 1977). The treatment passed imperceptibly from the stage of a creative if risky encounter into clinical malpractice and harm to the client. Overall, the overwhelmingly negative response to Trotter springs from an unwillingness to suspend the rules and to approach the material in a noncondemnatory fashion. Taking a different look need not preclude a judgment of Trotter and his work as flawed (Gabbard 1994). The advantages of a noncondemnatory exploration of the case are that it provides an opening for therapists to identify and explore the elements, choice points, and decisions that can make sexual boundary violation a seemingly inviting alternative for somedespite its being always and clearly the wrong course of action. Whether reading case material, listening to clients, or listening to ourselves, we are often confined by the stimuli presented to us. As a result, we think within the categories that suggest themselves or that are suggested to us. Breaking through these limitations of conceptualization can make the difference between the ethical (the sometimes unlooked at alternative) and the unethical (often asserting itself as the default or path of least resistance). I try to show in the following discussion, however, that the problems in the Trotter-Felini treatment extend to several other key areas besides the boundary violation. Furthermore, critical choice points, that properly pursued could have made the final outcome anything but inevitable, were not noted. To accomplish this task, I reexamine the case of Belle Felini and Seymour Trotter and suggest alternative intervention points and decision opportunities. If we can examine the material with an eye to Trotter as a colleague coming for supervision, we can provide him with a collaborative consultation rather than a condemnation. In this, we will have adopted a stance that is helpful and encouraging to other therapists in potential distress. Furthermore,

149 in so doing we will also address our capacity for handling our own ethical and clinical blind spots (Rubin and Amir 2000).

THE ERRORS OF SEYMOUR TROTTER

Before proceeding further, let me say that I am taken with the positive aspects of the fictional Trotter. I see him as an interesting maverick, a sensitive and possibly gifted therapist, a man aiming at honesty with himself, and a man of conscience. I also believe that Trotter failed to maintain honesty, failed to maintain professional involvement, and thus failed his conscience as well. Finally, I believe that Trotter could have been helped to see the case, Belles needs, and his own responses differently. This would have allowed him to better handle the case and produced a better outcome. As I imagine him, Trotter is a complex character who has within him the hubris, compassion, creativity, warmth, intuition, caring behavior, and disregard for convention that make him a person to reckon with. At the time of the Felini treatment he was a man under stress, deteriorating physically, and aware of it. In the process of retiring, he would probably be less connected with colleagues than before, and it would not stretch the imagination to think of him as someone whose awareness that his professional impact and therapeutic work were mostly in the past. Participants in my seminars have made several recurrent general criticisms of Trotter as a psychiatrist and as a person. One group interprets him as someone who basically wanted to conquer/bed Belle and therefore came up with the treatment plan and ultimate outcome that we have. A second group interprets Trotter as a person whose narcissism is the basic weakness Trotter is so intent on proving himself able to succeed where others have failed that his judgment becomes faulty. Undoubtedly, both these suppositions can be found reflected in the story. It is possible to write off Trotter, to conclude that his failure was the result of his

150 deteriorating health condition and agealthough it does not seem that way, given his portrayal by the author. One might instead see Trotter as a Promethean figure, punished for bringing fire to his client, and as one who has defied the fates by crossing boundaries in the name of touch and care (Eigen 1991). The Trotter who entered into the extended treatment contract with Mrs. Felini seems a more self-assured fellow that the one facing the ethics committee representative. Trotters failure is reminiscent of the Sayings in Ethics of the Fathers: Do not trust yourself until your dying day (Toperoff 1997). Certainly, as a kind of Greek tragedy where the respected professional suffers a downfall, this is a cautionary tale to many in the field (Quinodoz 1999; Roche 1956). Yet as constructed, his flaws are not so extreme so as to totally break empathy with the character. Trotter is drawn with an eye to his similarity to some aspects of the therapeutic ideal. To analyze Trotters story and focus on his clinical-moral failures is reminiscent of the virtue ethics literature (Anderson and Kitchener 1998; Cohen and Cohen 1999). This branch of ethics looks to the individual and the quest for right living as important: The question of the goodness and decency of the therapist is still not confronted intellectually by the profession (Lomas 1999, p. 9). As mentioned above, some clinicians assert that Trotter is not a virtuous therapist because of his actions and his motivation. One may also evaluate Trotter as sufficiently virtuous in motivation and operating more in error than evil design. As such, clinical error, rather than a failure of virtue, is implicated in the negative outcome. As error may be remedied more easily than failures of virtue, this perspective has implications for practice. In support of this perspective, we might examine the climax of Trotters difficulty in managing boundaries of the case. This situation occurs after a phase of successful treatment following the wager. A highly successful betting man in his resident days, he sees Belle Felinis request for an incentive to continue in the treatment as the opportunity for a growthinducing wager with the client and agrees to

ETHICAL DILEMMAS a weekend together as the prize for the client. Trotters myopia (literally and figuratively) is pronounced toward the end of the 2-year within-therapy contract. As the time to pay up and hold fast to the contract to spend a weekend with her approaches, Trotter becomes confused. Trotters anxiety, as this scenario becomes the more likely, may be considered a symptom of the struggle between his wish to sleep with Belle and his knowledge that such a course of action is morally wrong and perilous. This then suggests a conflict waged between Trotters wish to help Belle and his wish to help/satisfy himself; a conflict between his holding on to the thread of his professional career versus the wish to let go and let it fall apartmuch as his body has begun to do. On the other hand, the outside observer may view Trotter as unconsciously (as well as unconscionably) trying to lose the bet (and win the bed). If one sees him as a narcissistically motivated man approaching the case, the perspective shifts. Influenced by his hubris, his belief in himself, he is unwilling to accept that anyone else can understand the complexity of the case or the options involved as well as he. Thus he is caught both by his desire for the patients cure as the success of his treatment plan and his desire to protect his belief in himself as a unique therapist. He believes that he is capable of bringing about change. As such, he acts as if the private rules he and his patient agreed to are inviolate and take precedence over convention, ethics codes, moral and fiduciary duty, and so on. Of course, these views are neither mutually exclusive nor incompatible. Their interplay may well occur in the interpretation of the characterand they are both operant. Trotter himself struggled for a long time. But having strong feelings about a patient is one thing. Acting on them is another. And I fought against itI analyzed myself constantly, I consulted with a number of friends on an ongoing basis, and I tried to deal with it in the sessions (Yalom 1997, p. 16). Generally, all of these modes of action are considered valuable and as leading towards good practice. It is clear, however, that they did not provide the

SIMON SHIMSHON RUBIN remedy or protection that Dr. Trotter seems to have been sorely in need of. At this point, it is appropriate to consider what may occur if a consultant competent in both ethical and clinical issues is invited. The notion that a sensitive and alternative viewpoint can be of assistance in conceptualizing treatment as well as clinical issues has a long tradition and history in the field (Beutler, Bongar, and Shurkin 1998; Koocher and Keith-Spiegel 1998). Nonetheless, the complementary aspects of clinical and ethical issues and analysis have not always received the same reception (Bollas 1995). A Clinically and Ethically Informed Consultation: Late in the Treatment but Not Too Late The separation of consultation functions into clinically and ethically distinct components is probably a mistaken approach to work in the psychotherapies. The alternative conceptualization generally divines a direct connection between what is clinically and ethically appropriate. Where dilemmas are encountered, it is hard to imagine that they can be framed in terms of a conflict between clinical expertise on the one hand, and ethical expertise on the other. Rather it would seem that the conflict is between clinical and ethical rationales for a particular course of action and clinical and ethical rationales for a different course of action. The consultant utilizing both clinical and ethical expertise who is asked to respond to the case can identify see a number of choice points where a different course of action might have prevented the negative outcome to the case. By the time Trotter is aware he is in trouble, it is fairly late but not too late to reverse the negative slide of the treatment. At the stage of the wager where Trotter believed he had exhausted all options except for throwing himself at the mercy of his client, it is clear that his range of view is narrowed. He has lost his clinical and ethical equilibrium. At this stage several options could have been considered. Although the list below is far from exhaustive, it is meant to convey a sense of

151 how an objective view of the case might have been beneficial. Among the points to be made are those that follow. First, at the least, a joint consultation with Dr. Trotter and Mrs. Felini, with them going in as a couple/dyad in distress in need of consultation, could have been used. Undoubtedly, the choice of consultant would have been important, as one with an overly strict view of therapy might not have the ability to feel his or her way into the treatment, and one with an overly permissive (even if unethical) approach might miss some of the seriousness of the problem. In the literature, the pioneering article of Dahlberg (1970) who reported on such consultations might be of interest. In particular, such a consultation would explore with both parties: the multiple meanings of the wager, the role of transference and counter-transference (Racker 1974), therapist and client fantasy, issues of damage to the client in patient-therapist sexual contact (Pope 1994), and the power of action to obscure memory and therapeutic change (Freud 1914). In addition, the range of ethical dilemmas in this situation including duty to others (spouses and society) would be matters to consider. For the consultant to be able to be effective, he or she would be bound by the rules of confidentiality and their limitations. As therapist privilege is often classified as a relative rather than an absolute parameter of the therapeutic encounter, in the type of court case in which Dr. Trotter eventually found himself, this privilege for the consultant could be overridden by the courts. Second, although it may strike some as peripheral, one could stress the value of understanding the unconscious aspects of Mrs. Trotters relationship to the therapist. From a psychodynamic point of view, the consultation could reframe many of the dynamics underlying Mrs. Felinis wish for an honest and non-regulated relationship with Dr. Trotter. As the daughter of a mother who died in childbirth, the wish for closeness to parental figures cannot be underestimated. The emotionally and physically distant father of her life history is someone who makes the relationship

152 with Trotter seem to be a corrective emotional and physical experience. Even the ex-prostitute stepmother can be seen as an attachment figure that Belle seeks to identify with. To unconsciously emulate the transformation from a bad woman to one who has become respectable by pairing with the father figure is another level to understanding the meanings of the wager. As fantasy, these directions are important to pursue; as actions, these directions are equally important not to act upon. Third, a clear and unequivocal prohibition of the realization of the wager would have significant potential to foster positive change (Hundert and Appelbaum 1995). A clearer delineation of right from wrong, of societal versus individual roles, and of the proper bounds of intimacy and sexuality could be a very powerful organizing factor for Mrs. Felini. If Dr. Trotter is able to accept this limitation together with his client, the potential to be defeated by the reality boundaries of therapeutic morality could allow Mrs. Felini the ability to feel supported by societally validated limits. If both Trotter and Mrs. Felini are able to submit their secret to a responsible sensitive source who they trust, the context as well as the chain of events appear in a different light. Rather than dealing with private constructions of morality that are made in secrecy, Trotter and Felini would be coming up against the reassuring aspects of reality testing designed to protect them from the harmful parts of themselves and each other. This is a message of safe containment of dangerous as well as exciting feelings and could set the tone for working through of the impulsive behavior patterns that were the original presenting problem. Fourth, for whatever reason, if after or despite consultation, Dr. Trotter and Mrs. Felini remained convinced of the correctness of their planned tryst or overly driven to act upon their drives, there is still a place to recommend action. At a minimum, this would be a recommendation that the treatment be terminated prior to the initiation of any other relationship. According to the ethics codes of the American Psychiatric Association (Bloom,

ETHICAL DILEMMAS Nadelson, and Notman 1999) and the American Psychological Association (1992), such an action would not have absolved the therapist of responsibility for sexual contact with a client. On the other hand, it would have at least limited the expectation to continue some sort of quasi-therapeutic relationship in the therapy hour. Understanding that the sexualization of the relationship meant the total end of the therapy (as well as constituting an ethical, and in some jurisdictions, a criminal offense) would have been important to convey. In the novel this came as a surprise to the experienced Dr. Trotter and thus serves as one more indication of how damaged his therapeutic, as well as his moral, compass had become. Finally, to the extent that the therapy had effectively ended or was soon to do so, it would have been necessary to refer Mrs. Felini to a new therapist prior to termination. This action would have been designed to help her manage the meanings of the termination/implosion of the previous therapy with Trotter. Undoubtedly, the conditions to make such a referral work would have required a thoughtful search for an appropriate person. Quite probably, a woman might have been an appropriate choice. As part of the referral, it would be necessary to consider the extent to which the client would be open to, as well as best served by, another long-term therapy relationship. A thorough review of the issues involved for this woman who had suffered a series of losses of caretakers would have been best considered in the consultation (Emanuel and Emanuel 1992; Rubin 1997, 1999). These five points are representative of how a consultation with clinical as well as ethical knowledge could have been helpful at the height of the crisis in therapy. In the next section the perspective of the clinical-ethical consultation is broadened to examine its contribution to the range of thorny therapy issues that were apparent from the start of the treatment. The goal of the consultation is to allow the case to be approached (prospectively as it were) from a more appropriate therapeutic perspective.

SIMON SHIMSHON RUBIN Catching Mistakes Early: Another Look at the Felini-Trotter Therapeutic Encounter from the Outset When Belle Felini arrives at his office, Seymour Trotter meets her honestly and as a personand consents to hear her story. Some of the language is reminiscent not only of Yalom (1980, 1989) in his other volumes with an existential element but perhaps more recognizably in Rogers and others who stress the humanistic base of their therapeutic work (Frankel 1980; Rogers 1989) . Belle Felini is clearly a difficult client and the likelihood of treatment helping her limited at best. Beyond the titillating details of her physical sexual activities (and it is questionable of how psychologically sexual those activities are for a person like her), Trotter paid very little attention to the details of her story (as did many of the therapists who studied with me). Where do things derail for Dr. Trotter and Mrs. Felini and where might the treatment have been assisted to stay on a positive course? Several junctures have been suggested. The first one appears early in the treatment, where Mrs. Felini has the fantasy of coming home from a storm and being taken care of by an older man. In response, Trotter suggests to his client that they role-play the situation, with the therapist towel drying the clothed patient and making her hot chocolate. Mrs. Felinis response to the role-play confirms the power of the intervention as she cries and has a strong emotional response for the first time in this treatment. Belle Felini was not a patient to be approached with traditional technique. . . . (Yalom 1997, p. 7). It was instead necessary to invent a new therapy for Belle (p. 8). The role-play situation, performed under conditions of the therapists non-sexual (in the words of Trotter) contact, is an example of the therapists ability to reach the client. At the same time, a certain weakening of the boundaries between therapist and patient is intertwined with Trotters practice of this method, and with it potential for danger (Gutheil and Gabbard 1993).

153 Less dramatic, but no less potent a source of difficulty, is the management of the relationship between therapist and client. The transferential and countertransferential feelings in this case are in evidence from early on, and they are very strong. They present their own dangers to the proper conceptual and emotional approach to the client. And I liked Belle. Always did. Liked her a lot! And she knew that, too. Maybe thats the main thing (Yalom 1997, p. 8). The fact that Trotter eventually loses the ability to manage his strong and confusing emotions in his relationship with Belle contributes to the subtle erosion of the boundaries of the therapy. By the time his idealized view of himself as a proper if unorthodox therapist contradicts his commitment to the promises made to his patient and the risks to her well-being, he is too far gone to be able to identify his options or choices. Ultimately, he chooses from between narrow and fixed alternatives artificially limited by his own vantage point. An even earlier source of error, however, can be linked to the overly intuitive and fuzzy formulative approach that Trotter took to the case, although in the abstract it is perhaps hard to disagree with the idiopathic viewpoint of Trotter who approaches each client with a fresh perspective. With Mrs. Felini, he bases the approach on a history of previous therapies that failed as well. Trotters refusal to make a formal diagnosis on Belle Felini is questionable. Not just that I didnt make a diagnosis on Belle, I didnt think diagnosis. I still dont. . . . We were just two people making contact (Yalom 1997, p. 8). Even more questionable, however, is his refusal to consider alternative treatment plans at the outset of the treatment. Perhaps the first technical active error in the case is this one. As such, his apparent failure to formulate the case in traditional or nontraditional ways meant that he misses an opportunity to reorder the material and his conception of its meaning. These in turn, might have been useful to the structuring of the intervention. The role of the clinical and ethical consultation begins then with a reconsideration

154 of the initial contract with Mrs. Felini. At the time, Dr. Trotter conveys a strong sense of this woman as one in significant distress who is involved in life-threatening behavior. In his description of symptoms, one is immediately struck with the severity of the material.
A woman, Belle, walks into, or I should say drags herself into my office. . . . Depressed, wearing a long-sleeved blouse in the summertime. A cutter, obviouslywrists scarred up. . . . Long, self-destructive history. You name it: drugs, tried everything, didnt miss one. . . . Eating disorder too. Anorexia mainly, but occasionally bulimic purging. Ive already mentioned the cutting, lots of it up and down both arms and wrists liked the pain and blood; that was the only time she felt alive. . . . A half-dozen hospitalizations. . . . Nice husband, rotten relationship. . . . According to her, he had avoided her for years. . . . Nonstop therapyor attempts at therapysince her teens. . . . Dangerous sexual acting out. . . . Imagine driving next to vans or trucks on the highwayhigh enough for the driver to see inand then pulling up her skirt and masturbatingat 80 mph. . . . She got off on being in dangerous situations surrounded by unknown, potentially violent men (Yalom 1997, pp. 46).

ETHICAL DILEMMAS such as these were collected, but Trotter did not utilize them sufficiently in his formulation of the client or her therapeutic needs. From the viewpoint of a consultant, the information we have of Belle Felini warrants a number of conclusions and formulations about her at the initial stages of therapy. In the first place, it is fairly clear that Belle will not be a candidate for traditional insight oriented psychotherapy or psychoanalysis. The level of her impulsiveness suggests that neither of these approaches will be suitable for her in unmodified form (Pine 1985). Considering the early loss of her mother and the lack of a stable mothering figure (information returned to and elaborated later in this therapy but after the wager with Trotter has been undertaken), it is not difficult to surmise that her sexual acting out is related to the losses. It would appear that her relationship to her own body as well as her father and caretaking females have resulted in a disturbance of self, sexuality, and ability to form attachments. In considering what therapy to construct for Belle, the option of adding a nonverbal, nonintrospective therapy strategy (at least as part of the therapy package) could have been taken in alternate ways. It was not necessary to expect that therapy with a single person should be able to answer all of her needs. Furthermore, the importance of considering a female therapist would have been an important treatment option. Whether in conjunction with the male therapist, or separately, in a cotherapy dyad or as part of a larger treatment plan, a womans participation for this motherless child would have been an important part of therapy. Group therapy with women, focusing on issues of sexuality and self, might have been of value as well. Dance or art therapies, designed to allow expression of physical and nonverbal aspects of the person, are routes that could have been considered in constructing the optimal intervention. By avoiding the formulation of Mrs. Felinis needs and the areas where she was in need of assistance, Dr. Trotter underutilized the clinical use of the material. Furthermore, by believing that he alone could effect change,

Despite all this information, Trotter eschews formal diagnosis, although he emphasizes that he saw Mrs. Felini as a person with impulse control difficulties. Subsequently, he made attempts to increase her tolerance for frustration and self-exploration. Now Belle was not a good talking therapy patient. . . . Impulsive, action oriented, no curiosity about herself, non-introspective, unable to free associate (Yalom 1997, p. 8). There is a further element to her history in the area of interpersonal relations and attachment (Bowlby 1980). Belle had grown up touch deprived. Her mother died when she was an infant and she was raised by a series of Swiss governesses. . . . a father who had a germ phobia, never touched her, always wore gloves in and out of the home. Had the servants wash and iron all his paper currency (Yalom 1997, p. 3). Fragments of information

SIMON SHIMSHON RUBIN he set off on a road that directly led him to fail his client. True, Trotter sought consultation and tried other ways to better his understanding of the case. Unfortunately, his concern for Mrs. Felini is overshadowed by his faith in his own abilities to single-handedly provide all that she needs to undergo personality change. The belief in ones unilateral ability to perform these tasks could easily have complimented Mrs. Felinis belief and activity system. After all, it was her misplaced trust in her own power to defy fate, to seduce men, and to reignite the spark of life in appropriate and inappropriate ways that were particularly dangerous to her. Although the ways in which therapist and client are similar is recognized at different points in the story, the beneficial and potentially transformative value of both therapist and clients accepting limits was neglected. In my opinion, a careful formulation of all the material available at the early stage of the case would have been sufficient to identify most of the clients needs. Constructing an approach to therapy that would be sensitive to her personality structure and to the requirement that she be met with sensitivity and in ways appropriate to her needs and experiences flows naturally from this. True, it is unclear whether such a formulation would have insulated either client or therapist from what eventually transpired. Yet the approach would have identified Belle Felinis needs clearly, including the need to concentrate on maintaining boundaries for the protection of this client, her therapy, and thus her life. Knowing that a compulsive testing of limits might well characterize Mrs. Felini and were quite likely to appear in the treatment would have prompted precautions and preparations that may have been of assistance here. Could Dr. Trotter have been helped to treat the case alone? In the face of his concern for the client, his overwhelming sense of therapeutic omnipotence, and his pronounced vulnerability around his illness and dwindling ability to maintain his influence, it is not clear. On the other hand, a clearer perspective on

155 what was likely to transpire in the treatment and the risk factors present might have saved this treatment from derailing. The abrupt end to the treatment, and the eventual recombination of ex-therapist and ex-client in reversed roles of caretaker and patient, occurred outside of the therapeutic framework and without benefit of exploration or objective consideration. In the context of what we have seen here, those elements are sorely missed. They are consistent with the underattention paid to structural elements in the case and the therapy. The provision of a clinical-ethical perspective, in the form of an outside consultation, might have reduced these deviations from helpful clinical practice without sacrificing what was helpful and positive in the treatment. Had Trotter availed himself of such a consultation, the struggle between the knowledgeable, clinically sophisticated, and human side of him would have had a better chance in confronting the omnipotent, narcissistic, and vulnerable side of his personality.

CONCLUSIONS AND RECOMMENDATIONS FOR PRACTICE

The relationship of sound clinical practice to the adherence to ethical standards is a reasonable basis from which to approach dilemmas in the practice of psychotherapy. In the discussion of Irvin Yaloms (1997) fictional and wry account of Seymour Trotter and Belle Felini, it was my intention to show that a combined ethical as well as clinical consultation would have made a contribution to the management of the treatment. Spelling out the rules and laws can help practitioners learn the parameters of acceptable practice. It is important to help them (and us) with the occasionally overwhelming experience of managing the therapeutic human encounter when it propels us toward the forbidden or the dangerous (Pope and Vasquez 1998). In this, client and professional are better served if there

156 are competent-enough persons providing safe-enough places for the exploration and understanding of the clinical, ethical, personal, and therapeutic issues that can be so disruptive (Winnicott 1986). At a broader level, however, there are a number of proscriptive conclusions that can be drawn from this analysis. The first could be labeled Dont disdain the mundane. The mental health professional who disregards formal history taking, diagnosis and careful formulation of a case goes against established practice as well as legal and ethical guidelines (Koocher and Keith-Spiegel 1998). Good clinical technique suggests that we work and document our work in a careful manner. The willingness to forego the rigors of structured case organization and management can be associated with a sense of privilege, ownership, and omnipotence that are in and of themselves quite troubling. At the very least, such practice should be seen as symptomatic of a problem that needs to be understood and addressed. When the behavior is not seen as a problem, it would seem that the willingness to be master of all that occurs in the consultation room (according to ones own set of rules) is an initial harbinger of a type of boundary violation. Practicing according to established guidelines is no guarantee of proper therapeutic stance, but its opposite increases the likelihood of therapeutic error. Second, it would seem that helping the more disturbed and problematic of our clients and patients requires more than the usual sense of devotion to duty. The admirable sense of willingness to help others and to struggle against the odds needs to be balanced by a healthy respect for boundaries and reality testing. The psychotherapist whose ability to reach and make contact with difficult clients is often precisely one who can benefit from the boundaries, guidelines, and therapeutic consultative resources that are available. When the reality constructed within the therapy hour threatens the most basic rules and boundaries of therapy practice, the situation should be considered a crisis. Under these critical circumstances, no therapist can afford to trust his or her own judgment as to the wisdom

ETHICAL DILEMMAS of boundary violation without a thorough and honest outside consultation. Even more important, under such conditions no client can afford to trust the therapists independent and uninformed judgment. Third, the therapists intensive use of his or her physical person in a course of action with the client carries with it the potential for myriad complications. Role-play in the therapy hour, an attempt to provide corrective emotional experiences, heavy use of the transference relationship as a behavioral rather than interpretive aspect of the treatment, and the use of touch in treatment are each potent (and potentially toxic) ingredients in the therapeutic mixture. Particularly in the case of vulnerable individuals (e.g., persons with weakened ego controls, primitive personality organization, or a history of abuse), such procedures can be damaging and countertherapeutic. The fictional Trotters cavalier attitude to all of these activities of the therapist combined with his disregard for the clinical implications of his clients basic personality organization. The result (in fiction and in reality) predictably leads to both clinical and ethical disaster. Finally, the importance of appreciating that we are ultimately accountable in our work is an important aspect of maintaining a proper therapeutic stance. If what is happening in treatment is not compatible with professional and societal standards of conduct in treatment, then perhaps there is something wrong with the treatment, the standards or both. In the meantime, responsible practitioners will seek to balance clinical, ethical and legal requirements in order to maximize patient care within the parameters of the system (Rubin 2000). When the time comes to explain our actions, whether in legal, ethical, or clinical fields of inquiry, the rationale and circumstances for these clinical activities may come under close scrutiny. A carefully thought out (and documented) course of action, whose rationale and appropriateness are defensible, will support the moral claim of a clinician to adhering to clinical and ethical principles of health care. In all too many cases of actual psychotherapy (and in a manner similar to the fictional case of Trotter created by Yalom), no such claim can be made.

SIMON SHIMSHON RUBIN

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