It is both a pleasure and a challenge to review What Therapists Don’t Talk About and Why: Understanding Taboos That Hurt Us and Our Clients by Ken Pope, Janet Sonne, and Beverly Greene.

It is a pleasure because this work is different, in fact, unique.  Reading about psychotherapy ethics is often akin to pouring over the federal tax code - important, yes - but as dry as a statute, and difficult to assimilate. Worse, we might catch a whiff of catechism-like castigation.   What Therapists Don’t Talk About and Why is more than simply readable - it is entertaining, witty, and poignant.  It is refreshingly accepting, unabashedly human, and courageously honest.

It is a challenge to review because this is a work of tremendous ambition. Its goal is to overthrow the prevailing approach to psychotherapy ethics - that which begins and ends with learning established precepts. In its place the authors encourage a dynamic and flexible approach, founded upon self-examination and self-acceptance. When one becomes a therapist, one remains human - including all the base human frailties and conflicts. Yet, What Therapists Don’t Talk About and Why describes how we therapists can lose touch with vital aspects of our humanity.  It lays bare some systematic failings of our educational and training institutions. Whereas these should be teaching us to deal with common human reactions inherent to psychotherapy, the authors show how our institutions instead train us in denial.  To quote Pope and colleagues…

Most educational and training institutions where people learn how to do therapy seem to have not only the proverbial “elephant in the middle of the room” that no one mentions, but also a herd of giraffes, a mustering of storks, a flock of turkeys, a knot of toads, some lions and tigers and bears (oh my!), and, almost always, a grouse.

Simply pointing out the failure of therapist training and its implications for psychotherapy practice would render this an important book, but the authors have more in mind. They see the problem and propose to correct it. They walk us through what amounts to a practitioner’s guide to ethical practice. They provide us with exercises in self-examination that promote discomfort and yet increase self-awareness. Step by step Pope, et al. encourage us to venture ever inward, to locate and examine our human dark side where reside our uncomfortable and conflicted reactions to our clients, to our colleagues and ourselves. The journey stretches our tolerance for hitherto forbidden and avoided therapist reactions, all the while expanding our inner range and scope. Along the way the authors take the wrecking ball to well established, but unrealistic concepts of psychotherapist, that is, those chiseled in myth and taboo. By the work’s end they have generated an image of the ethical therapist as fitted with a distinctly human persona. Ethical practice becomes a natural byproduct of effective practice.

To accomplish all this Pope, et al. first sweep from under the therapeutic couch some common myths intrinsic to the role of therapist.  By myths they mean unspoken, unacknowledged, yet nonetheless, persistent and seductive beliefs or attributions, like the idea of therapist omnipotence or therapist moral superiority. These myths hover in the practitioner’s world, swirling in and out of consciousness, always exerting influence, complicating the therapeutic process, and promoting lapses in judgment.  Here is such a myth, one with institutional complicity, that most of us know all too well:

MYTH: If you’re a good therapist, the money will take care of itself.

On the basis of this myth many of us ventured into independent practice as babes in the financial woods, unknowingly primed for business failure and money conflicts with our clientele. Is it any wonder that so many complaints to licensing boards involve billing issues?

The myth also makes itself felt in the relative lack of attention that many graduate programs pay to therapy fees.  It is as if there were a belief that fee setting, fee collection, what to do about late payments, what to do about people who refuse to pay their bills, and so on were either irrelevant to the therapy or so easy that we therapists need little or no training in that area.

Here is the myth that is a central concern of this work.

MYTH: Learning ethical standards, principles, and guidelines—along with examples of how they have been applied—translates into ethical practice.
It is as if the answers to our ethical questions were already there in the code itself if we were sufficiently familiar with it, if we could open ourselves up completely to it and listen intently, passively receiving its wisdom without static or interference.

Myths are the fruit of taboos. Taboos are forbidden topics, mostly involving human frailties that by unspoken agreement are avoided in the psychotherapy community.  Paramount among taboos are therapist sexual feelings. Pope, et al. thoroughly examine the difficult history and sparse research on sexual feelings in therapists. One can almost feel the communal discomfort. Indeed, one can almost see the reactive professional stonewall give rise to taboo.  And yet, therapists are human, and humans have sexual feelings, and sexual feelings wend their way into treatment...

The therapy session focuses on anxiety attacks but your mind drifts toward what it might be like to have sex with the client.  You’ve worked with a client for over a year and feel such emotional intimacy during the sessions, then find yourself having very erotic dreams about the sessions.  A client finds you attractive, wears tight pants, and you can see he sometimes has erections during the sessions. You find you enjoy this....

“Where do we find guidance for situations like these?“

If you have read this far rather than skimmed, you know the answer.  The guidance can be found in, What Therapists Don’t Talk About and Why   Pope, et al. designed their book so it can also be used in carefully constructed study groups, They encourage the public exposure of the study group to foster acceptance of self and others, and render myth and taboo dispensable.  They list and describe ten basics of a study group environment conducive to the sort of relentlessly honest self-examination and vulnerable self-revelation essential to escape myth and taboo.

Before we embark on forming or joining such a study group, the authors recommend that we first get ourselves in shape to succeed.  They invite us to participate in an emotional workout, to examine our own experience, and bring forth into stark focus reactions that typically induce conflict and avoidance.  The emotional gauntlet consists of a series of conflict inducing questions.  The authors ask us to reflect upon our reactions, to linger and learn from them, and to respond with the most complete honesty we can muster.

Our responses to some of these questions may strike some—including ourselves—as confused or confusing, “politically incorrect,”  “emotionally incorrect,” ignorant, small-minded, biased, insulting, intolerant, prejudiced, dangerous, or a sure sign that we are not fit to be therapists.  That our responses might elicit such critical responses may be a clue to why the topics are often avoided.

Here are some of the questions:

Was there ever anything you decided either not to tell your therapy supervisor or to tell only in “edited” form?

What has a client said or done that has upset you the most?

What—if anything—has a client said or done or what could a client say or do that you would experience as sexually arousing?

Under what circumstances would you mention your arousal in your notes?

Have you ever imagined what a client’s body would look like if he or she were not wearing any clothes?  What feelings did this imaginary scene evoke in you?

Having reintroduced us to a slow-motion sampling of our own conflicted, and typically fleeting reactions, the authors illustrate how these emotions disrupt the therapeutic process.  They cite, label, and describe 17 types of “cues” that a therapist’s reaction to a taboo may have diverted therapy off course. As with the self-questioning above, we are invited to consider our own instances, in this case our own treatment cases.  Some of these cues are:

Therapy Adrift

If there is a powerful factor or taboo topic that the therapist alone or the therapist and client are working to avoid noticing, identifying, or addressing, the therapy may seem to drift aimlessly.

The Client-Friend

A therapist anxious about a client, therapy, or unresolved personal issues can avoid the anxiety by transforming the client into a friend.  The sessions can take on the give-and-take of two friends meeting over coffee, catching up on whatever is going on in their lives, discussing current events, and passing the time in a way that is enjoyable for both.

Fantasies, Dreams, Daydreams, and Other Imaginings

When therapists fantasize about a patient while masturbating or engaging in sex with someone else, it is a not-too-subtle clue that it’s probably time to consider how the therapist’s sexual feelings may be interacting with the therapy process itself.”

Now that we understand the intent of the book, and have limbered up by completing the self-questioning exercises and scrutinizing our caseload for cues of taboos at work, the authors put us through a sort of personal training session of their method.  They present us with scenarios and passages that veer sharply into conflict areas and ethical binds. They teach us to negotiate the territory by answering difficult questions.  In our study group we would discuss these with our peers. Here is one example:

The Note

You have just completed your third marriage counseling session with a couple who have been together for four years.  As you walk back to your desk, you find that one of them has left a note for you.  Opening the note, you find the client’s declaration of overwhelming feelings of love for you, the desire for an affair, and a promise to commit suicide if you tell the other member of the couple about this note.

QUESTIONS:

1) Would you initially address this matter privately with the client who left the note or with the two clients as a couple?  What do you consider as you make this decision?

2) How would your understanding of and response to this client’s “love” for you differ, if at all, if you were conducting individual rather than couple counseling?

3) What feelings does the client’s threat of suicide evoke in you.  How do you address this issue?

4) As you imagine this scenario, do you tend to believe that the other client is aware of his or her partner’s loving feelings toward you?

5) When you see a couple in therapy, what ground rules, agreements, or formal contracts do you create regarding confidentiality, “secrets,” and the scheduling of sessions with only one member of the couple?  Do you provide any of this information in written form?

6) When providing couple counseling, do you keep one chart for the couple or individual charts for the two clients?  How do you decide what information should be included in (or excluded from) the charts?   Would you include the note described in the scenario in the chart?

After responding to only the handful of scenarios in the book, the self-questioning method takes hold and easily generalizes.  We become comfortable in the labyrinth of the ethical bind and accepting of our heretofore forbidden reactions. Instead of freezing in fear or getting tangled up in proscription, we move toward and through conflict, newly confident that we will discover and examine core issues and arrive at a sensible course of action.

The final chapter addresses what we therapists can do when, despite our wide-ranging introspection and ruthless honesty, we nonetheless hit an impasse in treatment. Often an impasse is a sign that a taboo is at work. Pope, et al. provide us with a menu of ethical considerations that should help us navigate toward effective and ethical judgment.

What Therapists Don’t Talk About and Why: Understanding Taboos That Hurt Us and Our Clients is convincing in its exposure of crucial flaws in therapist training. It is enlightening about the destructive impact of myth and taboo upon psychotherapy practice.  Indeed, it seems naive to believe that any of us has been spared, and thus has no need for this book. In fact, that idea circles us back to the myth of therapist omnipotence. The proposed corrective method, the self-acceptance, questioning, and honest self-examination, has a friendly familiar feel to it - it is, after all, the same process we ask of our clients. It is like what driving instructors teach us to do in bad weather should our car start to skid - to regain control, first steer in the direction of the skid.  As we sit with a client and discover that we feel anxious, angry, aroused, or hear the soft song of any other disruptive siren, we now know what to do. We do not flee, nor seek refuge in myth - we steer toward the conflict. We tolerate taboo and use the self-examination method. We ask ourselves a series of questions designed to help us regain control, protect us from myth driven failures in judgment, and guide us toward effective and ethical practice. 

We emerge at the end of the book feeling the pleasurable exhaustion of the athlete. Our self-awareness is stretched, our balance improved. We have forged a new and powerful tool for our clinical repertoire. Indeed, we have constructed a new layer to our ethical foundation.  And our study group awaits. 

What Therapists Don’t Talk About and Why: Understanding Taboos That Hurt Us and Our Clients, American Psychological Association, March, 2006

Phone orders: 1-800-374-2721; more information & internet orders:  http://www.apa.org/books/4317105.html

Return to Top