The forbidden zone

God and the doctor we alike adoreBut only when in danger, not before

— John Owen c. 1563-1622

SHE IS fast-talking, intense, impassioned. He is calm, quiet, restrained. He is accustomed
to being the stillpoint of other people’s storms; that’s what psychiatrists do, day after day. This day, too, his clinical remoteness serves to distance him from the surrounding drama.

He has argued that this very quality is the reason she is so maddened. To be maddened is to be angered – or to go crazy. She claims her anger is justified; that he seduced her in his consulting room when she was at her most fragile, abusing her trust as a patient. “Dr MQ” denies it.

He claims “Mrs A” has a personality disorder and is angry with him because he maintained his professional distance when she longed for something more.

He speculates that she escaped into erotic fantasies to ward off a depression that she found terrifying. He says she turned the fantasy into fact to punish him and her husband for their perceived shortcomings, or because she unconsciously hoped one of them would stop the therapy she found so painful; that she then became so trapped in her web of lies that she had to pursue the claims to save face.

So they sit, this fine February evening, two rows apart, respective spouses at their sides, waiting for the verdict of the Medical Practitioners’ Board on charges of sexual misconduct against him.

There was a time when this kind of claim against a pillar of the profession might not even have made it to a hearing. Even a decade ago, many women who claimed that their psychiatrist, psychologist or doctor had sexually abused them were dismissed as hysterics, neurotically vengeful femmes attempting to be fatales.

But the professions are slowly – sometimes reluctantly – coming to the painful realisation that the truth is more often the reverse of this stereotype, with only 10 per cent of serious complaints turning out to be false. Of 44 cases of sexual misconduct allegations studied by Sydney psychiatrist Dr Carolyn Quadrio, 40 were substantiated.

Sexual misconduct is more prevalent than anyone would like to believe. American surveys have found that between 5 per cent and 12 per cent of medical professionals and psychologists anonymously admit to sexual contact with patients.

In Australia, “there is a high incidence, and I think it is much higher than we think,” Professor Richard Ball told a Medical Practitioners’ Board seminar in 1997. Ball is a member of the board, former professor of psychiatry at St Vincent’s Hospital and the head of Caselink, the Catholic Church’s counselling service for victims of clerical abuse in Melbourne.

He said: “I think what we are facing is something like what happened with the priesthood and so on, that it was all very quiet and then there was the beginnings of revelations about sexual misdemeanor and then it exploded, and now it is all over the place, like the wisteria.”
The MQ case is as tangled as any rampant vine. It has been the board’s longest and most tortuous: 40 days of hearings over two years, 4000 pages of transcript; his clinical notes, her voluminous diaries; her unyielding accusations and his flat denials. Murder trials have been dispatched with more ease.

The character witnesses for Dr MQ, a senior psychiatrist, have been a who’s who of Melbourne. There were the psychiatrists, the cardiologist, the neurologist, the sex therapist, the lawyer, the QC and the judge. They said the doctor, who is married with children, was a man of integrity. The allegations were unthinkable.

The main complainant is also married with children. She is educated, intelligent, articulate and well-established in her own profession. How could the stories of two such people be so at odds?

The answer lies partly in the peculiar nature of the psychotherapeutic relationship, in which rules apply that bear no resemblance to norms outside the consulting room. Psychiatrists and psychologists are more at risk than other health professionals of engaging in what one author has called “sex in the forbidden zone” – and of being falsely accused of such by patients.

Like the sorcerer’s apprentice, psychotherapists can find they have unleashed forces they cannot control. Sometimes one or both parties become so overwhelmed by their emotional and sexual yearnings – their internal realities – that they lose their grip on the external reality of the professional relationship.

If sexual boundaries are breached, the consequences for patients can be catastrophic. Quadrio found that most of the women in her study finished up with post-rape trauma syndrome and suicidal depression. Several were admitted to hospital, some involuntarily and some almost continuously for up to four years. Others lost their marriages and some previously successful women were unable to resume work and had to live on invalid pensions. One in a hundred will kill herself, says Melbourne psychiatrist Dr Sandra Hacker.

Patients pay money for the consultations that lead to all this. Sexual misconduct involves not just emotional abuse but Medicare or insurance fraud when patients are billed for sessions that consist largely of sexual or social activity.

Such encounters take different forms, but they often involve “love”. Not the kind of which the poets write – although it can feel like that – but the kind that Freud noticed in his patients when they took his “talking cure”, psychoanalysis. Clinicians call it “transference”. It develops to some degree in any relationship in which a person trusts, admires and depends on an authority figure, such as a GP or a priest.

In a rape case, the victim’s consent is a central issue. It is not with professional sexual misconduct. A recognition of the power of transference in psychotherapy is why Mrs A’s claims were seriously examined, even though it was clear she had been intensely attracted to MQ and longed for, as well as feared, a genuine sexual encounter with him. The fantasies in her diaries read like the erotica of Anais Nin. She claimed that the doctor had helped trigger this in her by interpreting some of the material she brought him in an unduly sexual light.

Transference is one of the reasons why even our criminal law holds that, when it comes to sex between mental health professionals and those in their care, consent is no excuse. Transference makes psychotherapy patients intensely vulnerable to sexual overtures by a therapist. Its destructive side – the patient’s reliving of infantile rage at perceived neglect or abandonment – leaves therapists vulnerable in other ways, including to false charges about what went on.

ASSESSING such cases can be difficult. Psychiatrist Dr Garry Sheehan, who spent 78 sessions with Mrs A, said she suffered from depression and, after her time with Dr MQ, post-traumatic disorder. She told her story to him slowly and with great embarrassment: “I didn’t get any sense of exaggeration.” His early notes recorded that her story rang “with pain and authenticity” but also that Mrs A had a curious smile, which led him “to feel the destructiveness of this woman”. He told the hearing that she did not have borderline personality disorder.

Dr Hacker, who had studied thousands of pages of Mrs A’s diaries, said she did have borderline personality disorder and that these patients made up the majority of false complainants. She said Mrs A’s diaries showed that at times she had trouble distinguishing between fantasy and reality.

Analytic psychotherapies, like the one MQ offered Mrs A for more than five years, are done with mirrors. The therapist tries to act like a blank screen, calm and remote. On to this emptiness, patients start to project feelings from much earlier relationships; they “transfer” those feelings to the therapist.

Patients “regress”, re-experiencing childhood traumas and developing the childlike vulnerability and intense emotional dependency on the therapist that they had to their parents or other significant adults when they were little. Like a small child, they can come to believe that they will not survive if they lose their attachment to this powerful figure. Sexual feelings for the therapist are common.

Tricky at the best of times, the transference situation can be disastrous if the therapist fails to deal with counter-transference – the feelings the patient awakens in him.

American writers Len Gabbard and Eva Lester say transference and counter-transference can feel just like romantic love; only the context is different. In their book Boundaries and Boundary Violations in Psychoanalysis, they write: “There is something inherently humbling in the notion of transference. The analyst must reluctantly acknowledge that forces are at work that transcend his or her irresistible magnetism. If any other analyst were sitting in the chair, similar feelings would appear.”
Therapists are supposed to be alert to the dangers. “If you fall in love in the middle of therapy, then you ought to be going off and having some supervision,” says Hacker, who is also federal vice-president of the AMA.

“Once upon a time, I used to wake up every Tuesday morning actually thinking about what I would put on, as opposed to just reaching into the wardrobe for whatever my hand fell upon. I thought, `This is funny, who am I seeing on Tuesdays that I want to get dressed up for?’ I made an appointment to go and see a colleague.”

Clinicians are honor-bound not to exploit the effects of transference. Abusers use it to manipulate patients into sex.

Zena Burgess, a psychologist and member of the Psychologists’ Registration Board, says: “It starts off with the therapist ringing to see how the client is between sessions, or he suggests that since the session was so distressing, perhaps they could
go for coffee or a walk in the park.

“Then it moves to being lunch before the session, or a hug after the session to reassure you that you’re OK. More and more, the boundaries between therapy and social contact are blurred, and then the sexual and the social becomes blurred … The client is groomed.”

A different psychiatrist, “Dr John Doe”, whose real name cannot be used for legal reasons, clearly used his skills to abuse his patients, according to evidence given at a medical board hearing. The patients said that if they protested at his behavior, he told them they were neurotic; he used his authority to set the rules of the relationship, denying their subjective experience and forcing them to accept his.

“Cathy” said she had gone to “Dr Doe” with severe anorexia and depression. She weighed 38 kilos, was a virgin and was terrified of sex. In evidence to the medical board, she said that he started by holding her hand: “I’d sort of be timid and he’d say, `It’s OK, I’m just consoling you’.” After a time, he took her to his house, and then to his bed, where she would lie beside him all night fully clothed, frightened by his nakedness.

Eventually, he told her she would have to provide sex or he could not see her any more. She feared losing her therapy, on which she felt her life depended, so she agreed. “(He) ripped off my top and sort of pulled me close to his naked body and I screamed and cried and he said, `It’s OK. Just hang on and get used to it. Just confront it … He would just tell me that I should face my fears.” During sex, “He would always say, `I’m not your father’, because I would be distressed and sometimes angry and flinching …”

Much of the sex happened during “consultations” in his rooms. Afterwards, “(he would) unlock the door and … push me out because I would be afraid and I used to say, `I don’t want to go out there. You can’t do this to me and just send me out there.’ And he said `you have to go out and learn to face the world’.”

If he dumped her out of his car miles from home, it was because “he would teach me how to survive and I should be independent”.

Another complainant told the board that she confided to “Dr Doe” that she had lost her father as a child and had badly missed having a daddy to read her stories. “Doe” would read children’s books to her before having sex with her.

After complaints by four patients the medical board deregistered “Doe”, calling him “amoral, lacking in any conscience and exploitative in the extreme … an evil person”.

THE TERM “sexual misconduct” covers a multitude of sins. There is assault of patients under the guise of clinical examination or treatment, usually the preserve of the disturbed GP. Some doctors have used hypnosis to try to disarm victims; others have used intravenous medication. A country GP was struck off last November after he fled following a pensioner’s report that he raped her while she was undressed on the examination table.

There is the professional-patient affair. A depressed practitioner who is lonely and vulnerable might be unwise enough to seek solace with a patient, as did one of Melbourne’s senior gynaecologist/obstetricians.

Things tend to proceed unremarkably until the professional tries to end the relationship – or until the patient finds out she is not the only object of his affections. Hurt and enraged, she reports him. Hacker says drily that advice from one medico-legal source to doctors contemplating such an affair is, “Don’t. But if you do, don’t stop”.

About 30per cent of offenders fall into the third kind of case. Their colleagues call them “sexual psychopaths”; devoid of empathy or remorse, they calculatedly prey on patients’ vulnerabilities. “They turn their consulting rooms into brothels,” Hacker says grimly.

More than 90per cent of sexual misconduct cases involve a female patient and a male professional, although all gender combinations have been reported. In 1996 a male psychologist was struck off the Victorian register for sexually abusing male patients, and in 1990 a leading Sydney psychiatrist and psychoanalyst, Dr Winifred Childs, was struck off for sexual misconduct over separate relationships with a female and a male patient.

Several cases – in Melbourne, Sydney and Brisbane – have involved leading figures who had been highly respected before they were exposed. In Quadrio’s study of offending therapists more than half were “high-status, high-profile, senior, and/or charismatic. They were qualified psychotherapists whose training had included both supervision and personal therapy. At the time of the offence at least two offenders were in therapy and another two were in supervision – both supervisors were offenders.”
While there is consensus that the responsibility for a sexual breach lies with the professional, there is debate about the degree to which some patients are “pre-programmed” to be seductive, particularly those who have been conditioned by childhood
sexual abuse to believe that they will not be cared for unless they offer their bodies.

Hacker says: “It’s part of your job to understand that, and the appropriate thing to do is to attempt to get the person to understand that this is a problem, and that they are going to continue to be victimised because of some of the messages they send out.”

At the same time: “It’s very difficult for you and me to sit here, being female, and understand what it must be like for some of these blokes, sitting in these chairs day after day. Some of my colleagues have told me about women disrobing themselves in front of them, offering them sex … It doesn’t happen all the time, but it does happen.”
In the case against Dr MQ a second complainant, Ms B, told the panel she had several times thrown herself at MQ: taking off some of her clothes, hugging him, trying to unzip his trousers.

The charges relating to this patient did not allege that the doctor tried to initiate physical contact, merely that he responded inappropriately with kisses and once, she claimed, an erection underneath his clothes. She said he told her, “I’m a man. I’m not made of wood, you know,” and “Come back when you’re not my patient and then I’ll kiss you.” The doctor strongly denied that he had responded in this way.

Quadrio emphasises that she found this kind of provocativeness rare in the substantiated cases she studied. She says the women she interviewed were not flirtatious or provocative but did long to be special. Many intensely idealised their therapist and it is this, she suspects, that offenders find “seductive”: “I think it has more to do with the ego of the person being admired than the people doing the admiring.” Like Narcissus, the offending therapist falls for the reflected image of himself.

It has been argued that patients might not be the only ones who enter therapy looking for love. Gabbard and Lester write: “Many individuals who choose careers (in psychotherapy) feel they were insufficiently loved as children, and they may unconsciously hope that providing love for their patients will result in their being idealised and loved in return … the desire to cure and the desire to be cured are two sides of a very thin coin.”

Self-analysis is a tool of this trade. The people who spend their working lives analysing other people’s dark corners turn searching lights on their own in the relative privacy of their professional forums. At the medical board’s seminar on sexual misconduct there were some telling exchanges as speakers struggled to understand why there is sometimes a gap between how fellow professionals should ideally respond to the issue, and how they actually do.

HACKER told the seminar she knew of three sexual psychopaths who had been supported by their peers: “A number of my colleagues behaved in what I consider to be extraordinary ways, had farewell parties for one of the doctors involved when he left the
hospital … (He was) not drummed out in any way.”

A female psychiatrist asked her what this might be due to; surely not just the feminist argument of a male hierarchy springing to the defence of men? Voyeurism, perhaps, suggested Hacker: “There is an enormous titillation involved in these cases and I suppose that our profession as a whole is pretty voyeuristic, really. I mean, we sit around listening to stuff which would burn the ears off most people …”

Professor Ball had another interpretation: “I would call it vicarious living, sometimes; of living out our fantasies through someone else’s behavior.”

And then, of course, there are external factors. Professionals’ reluctance to act can only be reinforced by cases where disbelief of allegations turns out to be justified.

In general, fantasy is assumed to be normal, even indicative of psychological stability and health … The pathological aspects … are restricted to those cases in which the fantasy becomes delusionary or when it dominates a person’s mental life and serves as a retreat from reality rather than an adjunct to it.

– Penguin Dictionary of Psychology

DR MQ was acquitted. Comprehensively. Ms B left the hearing room early, as it became clear that the medical board’s judgment was going against her. Mrs A stayed to the bitter end, alternately tearful and, along with her husband, derisory.

The panel saw Mrs A’s allegations as highly unlikely. She had claimed to have copulated on a rug and bare boards and the doctor’s room had always had wall-to-wall carpet; interruption would have been likely, given that his consulting room had no lock and could be partly viewed from another room; and the
doctor’s notes showed that therapeutic treatment had continued throughout their relationship.

When this unlikelihood was coupled with Dr MQ’s professional standing and personal integrity, the panel reached the required degree of confidence that “the alleged incidents simply did not happen”.

Dr MQ’s version of events was accepted over Ms B’s partly because much of his subsequent conduct, such as referring her to group therapy and to a female psychiatrist, “would appear ludicrous if the allegations were seen to be true”.

The doctor slowly unwound from the hunched-over frozenness he had maintained throughout. The panel members stood and began to file out of the room. The main complainant stood, too, and cried out: “Except you have lost the truth in what you have said!” But in this case, the verdict was that she had lost the truth, long ago.

The forbidden zone (Part 2)
Closing ranks
THE MEDICAL BOARD’S finding that the psychiatrist we have called “Dr Doe” was “evil” raises as many questions as it answers. So does other evidence to the board that suggested “Doe’s” exploits had been dinner-party gossip for years.Why is it that a trade that sells itself on its ability to understand what’s happening inside other people can’t keep itself free of dangerous misfits? Do professionals protect offenders by closing ranks, or by denying the significance of sexual misconduct?

Dr Carolyn Quadrio’s study (see main story) found that: “Women who pursued official complaints procedures were frequently thwarted by licensing bodies, medical boards and professional organisations which appeared to close ranks to protect therapists
… Some women were rejected by subsequent therapists.”

Says NSW Health Complaints Commissioner Merrilyn Walton: “They do close ranks. I think there’s still a culture – and it’s not just doctors – that (reporting) is like dobbing in a mate, and also they fear it will damage the profession broadly. The third reason is that they’re not sure that they themselves trust the system.”
A male friend of one of “Doe’s” victims told of going to a party at a psychiatrist’s house at which he raised the victim’s situation in abstract terms. He said, “The wife of the psychiatrist, who is one of my close friends, said, `I know who that is.’ And the psychiatrist said, `You have no evidence’ …. and then (the wife) actually said his name and it, in fact, was (`Dr Doe’).” The witness said he also raised his concerns more concretely with two other psychiatrists, neither of whom asked for the doctor’s name or suggested reporting him.

A second “Doe” victim said that her social worker “knew what he was like and she rolled her eyes and said, `Oh no, he’s at it again. Watch out. Watch out.’ And she said to tell him not to do it and tell him it’s illegal. So I wrote it all down on the palm of my hand … And I told him not to touch me and he just burst out laughing.”

A third reported that the male psychiatrist she saw after being abused by “Doe” seemed uninterested in her experiences; he was more focused on asking how “Doe” managed to afford his expensive hobby on a doctor’s income.

There is a big gap between the number of alleged offences that are known about and the number that reach a formal hearing. The president of Victoria’s Medical Practitioners’ Board, Dr Kerry Breen, believes there is a significant number the board never sees. In 1996 and 1997, a total of 13 doctors were disciplined for sexual misconduct.

But Quadrio says studies indicate that 50percent of Australian professionals have received at least one disclosure from a patient of abuse in a previous treating relationship.

Some doctors do not recognise what they are hearing or are not aware that an individual complaint relates to a pattern of behavior. Take the case of “Dr Bloggs” (not his real name), a GP whose registration was suspended after he admitted he had sexually assaulted up to 30 patients over 10 years.

He was finally exposed when two psychologists sent a letter to a female partner in his practice saying that they had just received their eighth complaint about him. The partner discovered that another local psychologist had received two complaints and a psychiatrist a further two, making a total of 12. Some of the partners had received individual complaints over the years but had not mentioned them to each other.

Even doctors who try to act can find themselves stymied. Dr Sandra Hacker, the federal vice-president of the AMA, told the medical board’s sexual misconduct seminar that two patients walked into her consulting room with complaints about the same psychiatrist. Hacker sought advice and was told that she could not report to the board because neither woman would be identified.

“There was a view that the college (of psychiatrists) would report to the board if there were further allegations … I was not actually given to understand what the critical number would be, or how many other psychiatrists had to ring up the college and say, `So-and-so is at it again.”‘ By 1997, the year she made these comments, things had moved “a quarter of an inch. The college now believes that it has the legal protection of qualified privilege.”

Today, the college’s code of ethics says psychiatrists must take “appropriate action” if they receive a complaint but does not specify what that is. “That’s because it may vary from case to case,” says Dr Joan Lawrence, inaugural chariwoman of the college’s professional conduct committee. It’s hard for doctors to act if the patient does not want to lay a formal complaint, she says.

Hacker says doctors might fail to act because they are uncertain what they should do, are reluctant to repeat allegations that they cannot verify, or fear being sued for defamation. Breen agrees that defamation is an issue. Doctors are protected from being sued for reporting suspicions that a colleague is impaired but have no immunity if a report of sexual misconduct is found to be unsubstantiated. A State Government review of the act that governs the board is considering the question.

The Government is also examining the problem of the struck-off practitioner. There is nothing to stop deregistered psychologists or psychiatrists from calling themselves “counsellors” and continuing to practise. “Dr Doe” did so for at least a short while.

Breen encourages doctors to call the board and discuss any concerns informally – anonymously, even – so that the board can at least get a sense of whether multiple patients are complaining about certain practitioners. It has also tried to reduce the trauma for all parties by employing counsellors to support them emotionally.

The task of disciplinary boards, though, is essentially to mop up the mess after the damage has been done. The question of how to prevent it remains.

Hacker holds out little prospect of detecting the conscienceless psychopath in time: “There are psychopaths in all walks of life, and they are charming chaps. Some of them are very bright and get to very senior positions in the judiciary, in politics. Medicine is not immune from these people.”

Professor Ball doubts that psychological testing would help with screening: “One of my worst murderers had had batteries of tests (because) he was in the military services. They were all perfectly normal; none of them picked up that he had been dangerous since he was 15, writing sadistic fantasies and so on. And there are books now telling you how to fake personality tests.”

Professional education might help. Researcher Heather Gridley asked GPs how they would respond to a complaint of sexual misconduct. She said they knew little of the procedures and tended to believe, mistakenly, that it was their job to question the complainant and verify the allegation before taking it further. “The women doctors were certainly much more prepared to be advocates for the patient. I think that’s a straight-out identification thing.”

Gridley, a senior psychology lecturer at Victoria University of Technology, sees a potential conflict of interest with registration boards run by professions. They try to protect the public, but, she says, “It’s like trying to do it with the handbrake on. There will always be a tendency to defend your own. It’s harder for professionals, even if they are aware of the issues, to take the position of the client.”

She believes the NSW system is worth considering. There, the Government’s Health Complaints Commission investigates claims and prosecutes charges before the boards. Here, the boards perform all those functions.

Professionals can only be dealt with formally if victims are willing to endure a public hearing (although their names may not be published). That might be before a registration board or in a criminal court (Section 51 of Victoria’s Crimes Act forbids mental health practitioners from having sex with patients). Patients have also successfully sued for civil damages.

Sometimes doctors believe the patient is too fragile to face a formal inquiry, although “many of us work hard to support victims when they do go forward,” says psychiatrist Dr Andrew Stocky. He’s not sure what can be done to make the system more complainant-friendly without impinging on practitioners’ rights to a fair hearing, but the current adversarial process troubles him: “I think it is very unfair that (damaged) patients are somehow being used to maintain our practice standards.”

Philippa Bolton also wants professionals to take on more of the responsibility for policing offenders. Bolton is still recovering from her years with one of Sydney’s most prominent psychiatrists, Dr Alexander Craigie Macfie. Macfie had been regarded as a “charming and talented” psychotherapist, according to colleagues, before sexual allegations by Bolton and others in 1996. The allegations remain unresolved because he left Australia to work overseas.

“I think it’s outrageous that health professionals don’t make complaints on patients’ behalf,” Bolton says. “The sheer weight of numbers should count for something. A medical board is not a criminal court; they’re not going to jail. People who are murdered don’t complain; evidence can be found in other ways.” And if a patient knows she is supported by many other informal complaints she will feel more able to lay a formal one, she says.

Bolton is cynical about the concern that reporting against patients’ wishes further “disempowers” them: “That argument lets the therapists off the hook – both therapists. It’s a matter of harm reduction. Just look at the statistics about the number of others who will be harmed if the offender is not stopped.”

Bolton supports the introduction of mandatory reporting. Victoria’s Health Services Commissioner, Beth Wilson, suspects it is inevitable but sees disadvantages: “It may be that the victims won’t come forward.”

Breen believes it would be destructive but acknowledges there are problems. “I think there may come a time, if we can’t get the profession to do better than they’re doing at the moment, that society might say, `Too bad; we’re going to mandatory reporting’.”

First published in The Age.