Give up your auld projections: A reverie on complaints and processes

by Iseult White

“We do not operate like the Gestapo, the Spanish Inquisition or the KGB”
Primitive fear abounds when members of a group feel compelled to use language like this, language that recalls centuries of persecution, torture, and genocide. The charged words are characteristic of the splitting and projective identification of a group that has stepped into ‘basic assumption’ functioning (Bion, 2003), where group members are operating from a paranoid schizoid position. At the heart of Bion’s theory is the notion, that on a conscious level, groups are working at sensible and agreed tasks, but inevitably from time to time they have “defensive reactions to psychotic anxiety” (189).

Totton (2001) believes that professional psychotherapy organisations have failed to contain their own fears and anxieties and instead project them outwards. I agree, but I would add that the projection is not limited to outwards, it shoots inwards, sideways, and every which way. This article is a reverie on psychotherapy complaints, considering issues particular to humanistic psychotherapists, grounded in real experiences of therapists who receive a complaint, clients who raise a complaint, and Chairs of Ethics committees. The reverie is held in a container of Bion’s theory of ‘work groups’ and ‘basic assumption’ functioning in groups, and concludes with a 21st century cautionary tale.

Complaints and the humanistic psychotherapist
One of the fundamental tasks of successful psychotherapy is learning to take ownership of one’s own projections and to find ways of making oneself less available to take on the projections of others. So imagine if the quote “We do not operate like the Gestapo, the Spanish Inquisition or the KGB” (origin unknown), came from a professional psychotherapy organisation in relation to complaint handling. For the committed psychotherapist, practicing from a place of good intent, the mention of complaints triggers barely acknowledged survival terror. What if I was complained against? How would I defend myself? Who would support and comfort me? Would my livelihood be taken away from me? How would I live with the shame and the fear of being exposed and humiliated in front of my peers, colleagues, and friends? These questions quickly arise but are just as quickly defended against. But the fear is so great it cannot be contained, and it emerges in latent projective identification.

In the book The mirror crack’d: When good enough therapy goes wrong and other cautionary tales for humanistic practitioners, the author suggests that most complaints result from the “therapist’s ordinary human error or temporary lack of judgement” (Kearns, 2007: 3). She states that many of the people who contributed to her research did not wish to be named “such is the culture of fear that surrounds complaints in psychotherapy and counselling” (Kearns, 2007: xi). She categorises two types of client who make complaints. The first want to challenge bad practice. They want to be heard and have a wrong put right, and if acknowledged and listened to, their complaint can be resolved quickly without the necessity of formal investigations and lengthy complaint processes, allowing the ‘good enough’ therapist to get back to the work of supporting clients.

Kearns (2007) is far more concerned with the second type of client, the client who wants the therapist to be “punished” (2). She suggests that some complaints processes support “an almost insatiable thirst for justice or even revenge” (2) on behalf of the vindictive client, who is in fact re-enacting, albeit unconsciously, revenge on a figure from their past through their malignant transference onto a ‘good enough’ therapist.

She believes that humanistic trainings typically don’t address the power dynamics of the psychotherapy relationship, and this leaves humanistic therapists unprotected against “vexatious complaints” that result from the “intractable negative transference” of clients that present with a relational capacity that is “significantly impaired” (4). By teaching humanistic therapists to hold the ‘therapeutic frame’ she believes that issues in the relationship can be contained in the relationship, thus avoiding unnecessary and vexatious complaints.

Springwood (2007) suggests that humanistic therapists run the risk of “being misinterpreted, and potentially abused by clients” when showing humanity and vulnerability in a therapy relationship that is based on a ‘real’ relationship (126). She suggests that clients take up a range of positions on a continuum that makes both client and therapist vulnerable to abuse, but seems to suggest that the therapist is more often victimised by the client.

Figure 1: Continuum of client positions in (Springwood, 2007: 127)

She suggests that clients with a history of childhood abuse become predatory and abusive and victimise therapists who must defend themselves and their good reputation. Her suggestion is that many complaints arise in this context resulting from:

Ruptures in the therapeutic alliance, intrusions into the therapeutic frame, unwitting mistakes in managing the transference, or the clumsiness that might come from inexperience or the carelessness that can come from stress and fatigue

(Springwood, 2007: 129)

When handled with attunement these situations come under the rubric of ‘good enough’ therapy, which has been misinterpreted or misunderstood by the client. Unfortunately because we live in a “blame culture” and have to deal with the “educated consumer”, practitioners risk being stalked by a legalistic complaint (130).

The therapist experience of complaints
Kearns’ research found that therapists who had formal complaints offered to them found the process to be traumatising and abusive, and believed the complaints procedures were at best naïve, and dangerous at worst. They felt like pariahs, shunned and exiled by their colleagues and peers on complaints and ethics committees and/or formal boards. Kearns believes that when a complaint does not concern a serious breach of conduct such as evident sexual abuse, or financial threats and intimidation, then a process of mediation that allows the client and the therapist to “co-create a resolution” (135) is more supportive of both parties, and should be the first step in a complaints process.

Other research suggests that mediation does not guarantee resolution for either party, and there are concerns that organisations can use the offer of mediation to avoid a complaint hearing (Rogers, 2013: 130). Like Kearns, Rogers found that psychotherapists who had received a complaint felt unsupported, bewildered and angry at the response of their professional body. The complaints process left them feeling raw and angry, and one therapist continued to feel that way, 10 years after the process, even though the complaint had not been upheld. Interviewees described the experience as (quotes come from three separate therapists):

It was really, really harsh and punitive and vile.

(101)

I want to say there was no humanity … in the process… it just felt… exactly like I was having to prove I didn’t do these things.

(101)

I’m crushed by it all. I feel now crushed and broken by the whole business. Maybe I’ll never work again as a counsellor.

(110)

Cautionary tale or psychotic phantasy?
Kearns’ research focused solely on therapists who received complaints, and for most of her subjects she had the dual role of trainer and interviewer, putting the research at risk of ‘demand characteristics’ or cues that make participants aware of what the researcher expects or hopes to find. She sees research as an “intensely political process” and one of her stated goals is to offer practical guidance to practitioners “on how to practice ‘defensively’ … in light of an increase in the number of complaints” against psychotherapists (Kearns, 2006).

At times her cautionary tales reminded me of one of my favourite childhood books, a copy of Struwwelpeter (Slovenly Peter; Hoffman, 2015) that once upon a time had belonged to my grandfather, born just as Victoria’s reign came to an end. The book tells “fearful stories and vile pictures to instruct good little folks” and uses verse illustrated with macabre pictures to tell moral parables. Hoffman, a doctor of psychology, quite probably intended to arouse psychotic fears. I doubt the same is true of Kearns, I suspect her fear mongering is more related to psychotic anxiety firmly blocked from awareness. Nonetheless her ‘research’ should be subject to some rigour. She has an agenda, and that agenda demands that we, as readers, take responsibility for the reflective and hermeneutic questioning, or ‘bracketing’ that is expected of a qualitative researcher (Ballinger, 2006; Fischer, 2009).

“Oh! children, see! the tailor’s come And caught our little Suck-a-Thumb.” Struwwelpeter

Red herrings and bogeyman predictions
There is no research in Ireland relating to complaints. None of the professional bodies publish statistics (as far as I am aware). There is minimal research available internationally (Symons, 2012: i), but three very different sources tell a similar story when calculating the rate of complaints as a percentage of registrants. Van Horne studied licensing boards in the US and Canada for the period 1996 to 2001 and concluded that “few complaints are filed, many of those complaints are not investigated, … and even fewer formal actions are taken against psychologists’ licenses” (2004: 175).

An examination of complaints made to the British Association for Counselling and Psychotherapy (BACP) in the period 1998 – 2007 shows there are less than 2 complaints for every 1000 members, and approximately one upheld complaint for every 1500 members (Symons, Khele, Rogers, Turner, & Wheeler, 2011). Most sanctions are not serious: a learning point, extra supervision, or a commitment to change a practice.

In order to understand if state registration makes a difference to complaint levels, both raised and resulting in sanction, I examined the rate of complaints raised for practicing psychologists in the UK Health and Care Professions Council (HCPC, which is the UK equivalent of CORU) fitness to practice annual reports for the years 2012 to 2016 (HCPC, 2012, 2013, 2014, 2015, 2016). The number of complaints resulting in a sanction is calculated using the overall figures for the register, as only the data regarding raised complaints raised is broken out for each profession.

The data from these sources is summarised in Table 1, showing the low and high figures for each year range and the standard deviation (SD). The SD clearly indicates that both the rate of complaints and the percentage of complaints that result in a sanction remain largely static year on year in each data set.

Table 1: Complaints raised and complaints resulting in a sanction as a percentage of registrants

Statistics are necessarily dense but the numbers tell an important story, one that contradicts Kearns’ perspective. The rate of complaints is low and the rate of upheld complaints significantly lower. The statistics across different geographies, obtained from professional organisations or licensed and regulated bodies, are strikingly similar, although the number of complaints raised and sanctioned by the BACP is lower than the numbers from the two regulated or licensed data sets. Symons suggests that members of the public struggle to navigate the confusing complaints systems of the professional bodies and regulation provides a single point of contact for complaints, making it easier to complain. The lower number of complaints upheld by the BACP might be attributed to self-regulation and Symons states the figures “raise an interesting question about the options available to professional bodies to effectively regulate their members and protect the public” (2012: 151).

Stalking predator or concerned client: Who raises the complaints?
For the purpose of this discussion the analysis in the BACP study is most relevant. Of the 56 complaints brought against the Code for Counsellors only 43% were raised by the general public. The remaining 57% were raised by other practitioners; 18% by trainees, 29% by members and 9% by related professions, for instance psychologists or psychotherapists trained in a different orientation (Khele, Symons, & Wheeler, 2008: 168).

Looking at the complaints statistics of the UK HCPC the number of cases raised by members of the public was 46%, while employers, third parties, and self-referrals made up the remaining 54% in 2016 (HCPC, 2016), and these numbers are consistent with the figures for 2012 to 2015.

The number of complaints is small, and the number of complaints raised by members of the public is even smaller. The reality is that ‘we’ are complaining about each other, whether ‘we’ indicates trainee, colleague, employer, or fellow practitioner. We are complaining exactly because we do understand the process of psychotherapy, and we believe there was something wrong, harmful, or unethical about the psychotherapy we received.

Kearns’ cautionary tales seemed to be based on an unfounded and exaggerated sense of fear, formed in the crucible of ‘psychotic anxiety’. Her book has elements of a reverse witch hunt, where the victim/client is scapegoated as the Wicked Witch of the West, in the nightmarish switching of the drama triangle (Karpman, 2011). Before assigning roles in the complaints land of Oz it is important to ground any assumptions and projections in research and data.

The client experience of complaining
There is very little research available on the client experience of offering a complaint. Rogers wonders if such research is still regarded as “too hot to handle?” (2013: 16). Symons received a number of emails criticising her choice of research topic, which expressed “a sense of anxiety and fear at the possibility of clients making a complaint”. The tone was both angry and defensive and the “anger and venom left [her] reeling. [She felt] hurt, vulnerable and under attack” (2012: 172). The psychotic anxiety about complaints makes itself known at the prospect of challenging truths.

Symons (2012) explored the reasons why clients decide not to bring formal complaints when they have experienced poor or harmful therapy. They felt shamed and silenced by their therapy. They feared their accounts would be disbelieved in favour of the therapist/expert’s testimony. They were concerned that they risked being harmed further by the complaints process and they worried that their therapists would pathologise them. They needed time to recover from the experience. Symons found that the effects were often long-lasting, significant, and damaging, and she finds it difficult to see the degree of harm being the result of what Kearns refers to as “minor failures” (2012: 246).

Rogers (2013) explored the experience of clients who raised a complaint. They reported wanting to be heard, respected, acknowledged, and understood. “I wasn’t after vengeance actually, I wanted resolution” (86). They would have liked an apology though no apologies were forthcoming. They wanted help to understand what went wrong and why. They spoke of the lack of support and information. Just like the therapists whose stories we heard earlier, there was anger, frustration and hurt about the hearings, which were seen as a “kangaroo court” (98) and “like the blitz” (108). Imagine the Dodo’s Caucus race taking place through the looking glass, rather than in Wonderland, a race where everyone is a loser and the only possible winner is the one who loses the least.

The fears cited by the subjects in Symons’ (2012) research were well founded. Some of the clients who raised a complaint were pathologised by their therapist during the process; “profoundly disturbed”, “a severe personality disorder”, “destructive” and “poisonous” were among the accusations made by their therapists (97). They found the process itself deeply traumatising: “I felt like suicide, I am sure it could have tipped somebody over” (95). Some will never return to therapy, “because I will never … trust or consider counselling again … I just can’t… I just cannot …” (110). But ultimately they complained because they wanted to make sure what happened to them would never happen to another person. They were not seeking vengeance.

This guiding principle supported them during and after the process, and allowed them to retain a sense of dignity and reclaim their power, no matter the outcome.

The experience of Chairs of Ethics: An important but unheard voice
While there is little research on the experience of clients, there is even less research on the experience of those involved in handling complaints. Rogers (2013) spoke to six Chairs of Ethics. They reported feeling deprived of the support of the members, and they spoke of anxiety, isolation, loneliness and feelings of responsibility (115). Chairs reported becoming obsessively secretive in a bid to manage the demands of confidentiality. They had no effective way of sharing the burden due to “terror of leakage” and concerns about confidentiality (75). They spoke of conflict between transparency and confidentiality and recognised their position as receptacles for projected fears. “Difficulties came from the high level of projection from the membership and the public” (75). One chair was quoted as saying her work on the Ethics committee “brought up massive amounts of guilt and shame … maybe …we are all acting something out by being part of this process” (75). Those organisations that had lay members on their panel spoke enthusiastically of the contribution they made, though only 27% of UKCP organisations use lay members on their panels (79).

‘A state of chassis’: Uncontained, stagnating, and untruthful
When a group is in ‘basic-assumption’ functioning, strong emotions — hate, anxiety, fear, guilt, oppression, humiliation, shame — take hold and the outcome is “stagnation” and “platitudinous, dogmatic” thinking (Bion, 2003: 128). The group makes a tacit and unconscious agreement to shift away from work group purpose “as if in response to some unexplained impulse” (188). None the less the group ‘appears’ to be of one mind and ‘feels’ as though it is working. Complaints processes are discussed, reviewed, reworked, terms of reference are drawn up, and opinions and feedback are sought. But the dynamics of basic assumption functioning leaks out in splits, factions, secrecy, and solemn talk at biannual tri-partite meetings that make pronouncements and produce plans that never materialise. Everyone feels as though they are working but in reality they are building a famine road “from nowhere, going nowhere” (Boland, 1987: 296). Subgroups act out ‘part-object relations’, there is no whole, no integration, and no containment.

Even “sophisticated individuals” (Bion, 2003: 128), such as fully trained psychotherapists, supervisors, and committee members with many years of experience, find it difficult to step outside of basic-assumption functioning. The few that spot the denial, avoidance, splitting and projection, and dare to challenge the group on the platitudinous dogma, are at best ignored and written off as uninformed, shrill, or reactive. Chillingly, if not ignored, they are likely to be attacked and scapegoated, for daring to perturb a group sanctioned psychotic phantasy.

I believe this stagnation is clearly evident throughout the complaints processes of many psychotherapy professional bodies (UK and Ireland), and in the dramas and internecine fighting around State regulation versus self-regulation. Despite new complaints processes meeting the Professional Standards Authority in the UK, the website www.unsafespaces.com continues to highlight abuse and safeguarding issues that have gone unchallenged or unsanctioned. Similar stories may not have emerged in Ireland yet, but collective and individual failure to confront misconduct prevents practitioners, psychotherapy agencies and professional bodies from learning, and leaves clients in further danger of continuing exploitation (Biaggio, Duffy, & Staffelbach, 1998).

Bion says that work group mentality is a creative space where ‘thoughts in search of a thinking’ allow the emergence of new approaches that are rooted in the drive for truth to emerge. Basic assumption functioning feels threatened by truth and has a “hatred of a process of development … a hatred of having to learn by experience at all” (Bion, 2003: 89). The truth withers and dies in basic assumption functioning and issues are hidden “under a veil of secrecy disguised as confidentiality” (Rogers, 2013: 156). One simple change to complaints processes would be to demand the truth of all participants and if it can be later proven that a participant knowingly made material false statements during the complaints process there should be immediate grounds for appeal or sanction.

What would allow a move back to work group functioning so thoughts can find a thinking? At the very least we all need to give up our auld projections, and share the burden of complaints, as individuals, agencies, supervisors, trainers, training organisations, and professional organisations.

One final cautionary tale
To conclude I would like to tell you a cautionary tale. I shall borrow a story already told from an experienced psychotherapist, as he looks back on his therapy relationship with Sue, also a psychotherapist (Hobson, 1988). He describes how he dropped into a dark hole of “no being”, the terror of non-existence (269). He says:

Again and again I repeated my mistakes (262) … Sue brought home to me that deep down I shared her chaotic splitting. At times, my counter-attacks were more vicious (because more disguised) than her attacks (266)…

I often said
‘I wish her dead’ (262)

Sue committed suicide. On a grey Thursday (265)

A twisting stab
And my guts knew
That I died too
That day.
In a way. (262)

I, myself, and mine, we met a psychotherapist who had fallen into a dark hole of “no being” but, unlike Sue, I am alive, and almost kicking again.

It was a close shave, one that emerged in the “sloppy optimism” (Gendlin, 1998: 23) of ill- informed and ethically bereft psychotherapy, in an organisation hoisted high on hubris in a professional body beset by basic assumption functioning. In a way.

That shadow will never fade while the shroud of basic assumption functioning prevails.