We met several more times in June, at least twice and sometimes three times a week. Sam told me that she was not billing insurance for all these sessions. I took that as an indication that she had realized what a terrible mess she had made of me, that she wanted to at least attempt to mitigate it. But it turns out that she not only billed insurance, but on several occasions she double billed them and on one occasion billed them for a session that didn’t take place. So place that on whatever scale you use to measure honesty.
From the beginning of July through mid-September 2021, Sam continued to “treat” me, even though my mental condition was deteriorating. The boundary violations during this time were severe and frequent. Among other things, Sam consistently blurred boundaries, engaging in behavior that Schoener (1989) would classify as “role reversal,” where the therapist seeks validation or emotional support from the client. I went from hating myself to hating her to thinking she was the only person who cared for me. This nearly three-month period was intensely painful, and I repeatedly told her that continuing the “therapy” was causing me harm.
One particularly egregious incident occurred when I ended a tearful session by saying “I love you.” Sam said she didn’t know how to respond. When I told her to respond honestly, she replied, “I love you.” This exchange exemplifies what Devereux (2009) describes as a “violation of abstinence,” where the therapist fails to maintain emotional neutrality and instead gratifies the patient’s wishes in ways that can be harmful. To be fair, there was no right answer. The “I love you bell” could not be unrung without causing her to admit to having lied previously.
I had very quickly written off the idea that there was any sort of romance to be had. She was clearly in a protective mode where there was no chance of that. And that would have been better if she didn’t persist in pulling me closer by frequently telling me how authentic her feelings for me were, amping up her disclosures about her life, her family, and engaging in role reversal where she was looking for validation from me.
Here are some quotes and what I made of them during the last three months before I felt I had to just cut it all off.
I’ve asked myself, you know, how did this happen? … I think there are times when I don’t elaborate enough. I make these assumptions that there’s a shared meaning. Well, which there is: we both know what love means, right? But in the context of our relationship, like saying, ‘I love you.’ It conveys a good amount. But it’s sort of left out there in a way, it seems to me. And I have at times tried to elaborate on what I mean by that. But not in a way, I think, where there’s a finished shared understanding, and I’m not backpedaling from anything that I said or felt or feel.
To which I responded that these were not science words, aren’t hard words to understand. And that I had brought up each and every one of them, either in the moment in most cases, or shortly thereafter. So, it shouldn’t have just been a question of elaboration, it was a question of why use charged words in the first place and why, after I reacted to them each and every time, continue to do so?
I absolutely understand and appreciate using a word like “lovers,” it’s very charged. And maybe there was not enough sensitivity on my part. And not even sensitivity. Maybe, I don’t know, not enough caution. Around the words that I was using. I was thinking to describe, like, to not pretend like it [Sam’s counter-transference] wasn’t there.
So, what do I mean, because I said deeply immersed in the same conversation that I said that I love you… What I mean by deeply immersed is with you, in it, feeling it, as open as I can be to feeling everything that’s happening between us. Reaching for you, wanting to know you, wanting to know more. And not in a separate kind of way. Like there’s a kind of a merger that is an intimate experience.
Again, not science words. If there was a song called “I’m Deeply Immersed in You” it would be a love song, not a ditty about how well we’re rocking our therapy.
But that’s what we did differently. I was conscious of the boundaries and would not and did not use that language. I certainly described my feelings about her, and I had warned her that I was vulnerable to being hurt if we didn’t keep things clear. I had posted the warning signs and she blew past them. Why she would not have had caution when I’d explicitly and repeatedly cautioned her is a mystery. She reiterated that, “I don’t just toss things out.” So this was part of a plan?
I didn’t know what to do with the idea that she experienced our relationship as a “merger.” That too seems like a word you’d use around a romantic—or, at least, non-professional—relationship. Merging is the process of two becoming one, and even if you take any of the sexual implications out of it there is still a level of closeness and togetherness that would seem to go beyond therapy.
In the May conversation in which I’d told her that it was she who used “boundary-busting language,” I’d told her that it catches me every time because in my experience she is not an “uncareful communicator” and so that language had to be conveying something. She agreed, at the time, that it was.
One of those pitfalls, from my perspective, is that you were wanting me, needing me to say more about my experience with you, how I felt about you, how I feel about us. And my telling you that I love you and that I’m deeply immersed with you was my effort [to be both the participant and the enforcer of the frame]. And there’s a safety that goes both ways, because I do struggle. I do struggle. I take great risks when I say things like that to you.
In that last sentence she acknowledged how far outside of the boundaries she had come and what risks she was taking in doing so. I do not know—and will never know—whether the risk she was concerned with was the effect on me or the risk she took to her own professional ethics. But as she persisted in doing so, it’s worth noting that neither of those are good reasons to continue speaking to me in that way.
Incredibly, she blamed me, her patient, for the boundary violations, even though, according to all professional rules, maintaining boundaries was solely her responsibility. Indeed, as Dr. Appelbaum wrote in a previous post, if Sam could not maintain her boundaries and also be emotionally connected to me as her patient, her professional obligations required her to prioritize the maintenance of boundaries, even if that meant terminating the relationship.
One of the things that I was thinking about in the “what happened” and in the use of language that was confusing and felt seductive. I thought especially of the phrase deeply immersed and I thought: how is it that I can feel in moments so deeply immersed with you? Like, where does that come from? For me, from you, like how has that happened and it led me to… my understanding, it comes from [the fact that] there’s something that I know about the kind of pain that you’re describing, the feeling that you have so much to offer and you’re there for it and you have these experiences and relationships and I firmly believe it starts from the beginning of time, of being disappointed, of yearning for more and being disappointed so I know what that feels like from my own history, I know what that feels like.
Sam expanded on the way she identified with me, disclosing the very personal source of her “yearning for more” and “disappointment”:
Well, it goes all the way back. It goes all the way back to the beginning. You know, there are ways that my mom was… had turned 17 a week before she had me… Very, very, very young mother. She married my dad when she was pregnant with me. They both came from poor backgrounds, and neither one of them had a lot of support. My mom hadn’t even graduated high school. And so, she was a kid when she had me and there were many ways in which she wasn’t able to rejoice at having a baby.There were ways in which I imagine she had to feel very encumbered, feel like her adolescence and her early adulthood were sort of stolen from her. I mean, she let me know she felt that way. So, there were ways in which I needed my mom’s presence, or where I wasn’t able to have that. And that was my template. And so, as we all do, I molded myself to best figure out how to keep myself okay. And also, how to get her attention and how to get her love. Sometimes successfully, oftentimes not successfully. And I know that pain and then going through life, that’s my template. I find familiar aspects of that, in relationships with girlfriends, with boyfriends, and I’ll zoom out and say, there’s a way in which that’s always the case, right? Like, we have to live with the loss, of all love being conditional to some degree, and all love disappointing us in ways. I will say, you know, she’s 74 now. And she lives in the same town I live in, both my parents, and I see them every week. So, you know, I have a very close relationship with them. But as close as it is, part of that relationship is living with this history, and my having to come to terms with it. It’s taken a long time.
Another in a long list of things she should never have been telling a client. And not actually relevant to my life experience, only to hers.
But how could a story like that not make someone feel empathy for her, feel that pain she described from early in her life, wish they could have somehow made it different and better for her?
She even told me that she thought her mother was a “sadist.” This came up in the context of discussing a case study she’d sent me where the writer, a psychologist, had referred to her client as a sadist, which I questioned.
Okay, so I’ve got a story. There was one year when I was growing up, I was in my teens, and I really wanted this particular pair of earrings for Christmas. And my mom told me – I mean, I really wanted them, so I cut out the picture and I showed it to her and I would ask her about it – and she would say things like to me like, ‘oh, you know, not this year, Sam,’ you know, whatever it was, like ‘we can’t afford it this year’ or ‘I’ve already finished my Christmas shopping,’ I don’t remember. So, I still held out hope that I’d get those earrings and so Christmas day and I opened my presents and there’s no earrings and she says something like, ‘you look disappointed Sam. But you know I told you I told you I wasn’t going to be able to give you those earrings this year.’ And I said ‘yeah, okay, okay.’ And I’m a little disappointed and then she says, ‘oh wait what’s that on the back of the tree?’ And I go to the back of the tree and there are the earrings, like not in a box. They’re like ornaments hanging off of the tree.
There’s a bit more in the recording than in the above quote, of me asking why that constituted sadism. I loved that she told me this story and Sam acknowledged that she was giving me the mutuality in the relationship that I’d been wanting for a long time. She shared what she called a similar experience in her own psychoanalysis: When she was in school for her MSW or LCSW, she was required to engage in her own therapy. She too found that she wanted her therapist to give more of him or herself and she articulated that to the therapist, but the therapist (properly) would not do so. It made the experience of therapy unpleasant for her and she ended therapy as soon as she was able to. I wonder now whether a lot of this came about because she wanted to not be like her own therapist, who had denied her the more fulsome relationship she told me she’d wanted and so chose to violate the boundaries that her therapist did not in order to give me what she herself had wanted. I also wonder whether her previously expressed “need for more” that had played out over her life because of her difficulty attaining her mother’s love had made her want love wherever she could find it and I was simply a ripe candidate because of the vulnerabilities I’d expressed (and she’d egged on) about my marriage. I will never know.
Sam continued to try to convince me not to terminate “therapy” with her by continuing to disclose very personal details about herself. For example, she told me that her mother went to college when Sam started high school, and that her mother graduated college with honors in accounting, but never worked because she was too afraid of failing it to take the CPA exam, instead working as bookkeeper for her father’s construction business. She then disclosed details about her parents’ marriage, telling me that, though their marriage was forced by circumstances, they had come to have something like a loving relationship, even if it began with dependence. These stories were giving me something I wanted: the ability to know her better. I thanked her for telling me. In another reversal of roles, she replied:
It was easy to tell you. And I say that in the context of saying when you first brought that up, you know I registered a discomfort about – not formulated, but the feeling of, if I’m going to put words to it – how do I feel about sharing that? What is that going to be like? But it actually was very easy to share that with you.
That ease is something that we very much had with each other, and as we worked through the summer, I believe Sam saw the solution to my breakdown being to open herself up more. I was certainly asking for that. But it was the exact wrong thing to do because that opening, that increasing closeness also felt like a breaking down of the boundaries between us, so when those boundaries came up, they felt that much sharper, that much more unexpected, and that undermined the trust I was able to have and the vulnerability I was able to display.
I’m going to say something – and I’m taking a risk right now, but it doesn’t feel like so much of a risk – which is, and I can’t tell you, I can’t formulate an explanation, but what I can say is in my gut, come what may, I’ve never felt freer with you.
She shouldn’t have felt free at all to tell me about her personal life. Nor to have let me believe that I had access to an intimate part of her that other patients did not, which I surely did believe.
And then came the decline to the end and the aftermath.
Boundary Violations in Psychotherapy - A Personal Case Study 