Boundary Violations and the Fall From Eden

There has been a lot of water over the dam in the 10,000 years since the beginnings of agriculture and complex urban societies. For the million and a half years preceding that, human social organization had been more or less the same. Even while developing upright posture, tools and language, those species that carried the DNA sequence that defines the hominid line -- Australopithecus afarensis, Homo erectus et al. and finally Homo sapiens -- roamed their mostly African ranges in small hunter-gatherer bands thought typically to consist of 20 to 30 closely related individuals. In this evolutionary context, if you helped someone survive (e.g., shared your food, nursed the injured) you could reasonably expect to receive help in return when you needed it. You and your comrade had a history together and such mutual helping benefited you both, bettering the odds that your own DNA sequence and/or your friend's (likely very similar) would propagate through time.

Such is the story evolutionary theorists have been telling us for the last 30 years about the origin of mutual helping behavior, or in their language, reciprocal altruism, in humans and many other social species. The fulfilling inner experience we helpers have, according to these theorists, is epiphenomenal to the calculus of gene propagation; it is a good feeling that simply reinforces the most adaptive behavior just as surely as the "cute response" that moves mothers to nurture and protect their offspring. (The analogous response in mice can be removed by knocking out a gene called Fos-B; indifferent mother mice lacking it let their children starve.)

It is no wonder that this story has fallen mostly on deaf ears in the mental health community. Most of us resent having our most cherished ideals reduced to organic chemistry, even if we are comfortable wielding chemotherapeutic treatments. And yet, incomplete as it is -- and often half-baked, as presented in many popular books -- the evolutionary argument, in my experience, casts a revealing light on the personal evolution of many a psychiatrist.

Most of us begin as idealists eager to care for people, but few remain deeply engaged with large numbers of very needy patients after a decade or so. Aside from leaving the profession, there are two adaptive escape routes. (This was equally true before managed care, although the proportion of psychiatrists choosing each has been altered by it.) Both are attempts to survive the overwhelming emotional pain and need in whose path modern society places psychiatrists as specialized professionals expected to deal with it -- in exchange for pay -- and under circumstances wholly unlike those in which our capacity to meet needs and to solace pain developed.

In one typical escape from this overwhelming situation, the established psychiatrist in private practice progressively sets limits on the number and severity of cases they see. The chaotic borderlines or those with refractory Axis I syndromes are left to the big systems or to the newer private practitioners.

A second escape route, open to academic and institutional psychiatrists, is the retreat into some form of professional detachment. This appears variously as a theoretical or research orientation; focus on therapeutic technique, administrative procedure and systems management; or, more simply, the superficial med-check routine.

A third, non-sanctioned escape leads psychiatrists to impairment, addiction and boundary violations with patients. The latter will be our main concern here. I will argue that it can be seen as a perverse attempt to get reciprocal altruism to really work; to get something tangible back from patients by way of meeting personal needs inappropriately.

At best, experienced psychiatrists pick and choose where they get deeply involved, consciously aware of the need to conserve themselves for the long haul. Whatever their chosen escape from the undiluted, overwhelming needs of limitless numbers of patients, they do not turn up their noses at colleagues who have responsibly chosen another. And at worst, the private-practice therapists sneer at their institution-based colleagues for overmedicating patients and not listening to them, while the institutional psychiatrists sneer back at the psychotherapists for avoiding the heavy work: large numbers of very difficult patients.

Rarely does either group see a connection between its own choice and that of the third, impaired and/or boundary-violating group. We quickly distance ourselves from them without so much as a "There but for the grace of God go I." If we deal with our unconscious fear of falling into this quicksand ourselves with unalloyed moralistic denial, we label these "fallen" psychiatrists as sociopathic predators. (Of course, a small minority of them are.) Or, if our intellectual defenses have a more sophisticated polish, we may come up with some Kohutian verbiage about grandiose mirror transferences and narcissistic merger. Whatever our preferred explanation, we are steadfastly talking about something that happens to other people.

These explanations (particularly the Kohutian verbiage) are not without merit as far as an understanding of individual psychology is concerned. But they serve to distract us from an incontrovertible fact that both Darwin and Freud, in their different ways, brought to our attention some while back.

Human beings were not genetically designed to live in the social world in which they now find themselves. Psychotherapy and medicine are among the "helping professions" unknowingly assigned to deal with the personal consequences of this simple fact. In focusing on the individual psychopathology of each fallen psychiatrist -- I use the language of Eden purposefully here -- we neglect the collective significance of the phenomena of boundary violation and impairment themselves.

In the modern professionalized situation, the bottom drops out of small-group reciprocal altruism. As isolated and anonymous individuals encounter each other, having little past or future together, two things happen. The first is that, without the support of a true community, the limits of an individual helper's resources are reached sooner and more often. There are not enough helpers to go around. The second is that the help-seeker often brings a greater backlog or depth of unmet need, as well as depth of frustration if current needs are not met, to each encounter. In this context -- on purely Darwinian grounds -- altruism ceases to be so attractive. Competing and more immediate self-preservation instincts gain a stronger position. The helper often shifts, under their influence, to strategies that are sure, in the near term, to conserve resources: ways of obtaining immediate gratification or discharging uncomfortable affect at the help-seeker's expense. It is in this perverse sense that the helper is trying to make his originally altruistic involvement deliver some reciprocal benefit, or at least stop being a drain.

We in psychiatry have become quite skilled at constructing high-minded theoretical rationales for rejecting needy, messy patients. They need to experience limit-setting, to develop internal motivation and so on. It is for their own good. (Interestingly, some of the more successful innovative treatments for difficult patients, like assertive community treatment teams and a more relapse-forgiving substance-abuse treatment, throw these compliance rationales out the window. They dilute the patients' need through team approaches and group modalities that recall the hunter-gatherer bands of yore.) The sense of emotional relief that occurs after "limiting" patients out of our lives should tip us off that something instinctual, not just theoretical, is going on.

There is another form of objectification aside from the purportedly theoretical one of limiting patients out. It leads to exploitation of the help-seeker for the helper's own gratification. Here, too, one sometimes finds that boundary-violating therapists have constructed quite a coherent theory about what their patients needed to experience. Most overt therapist-patient sexual boundary violations occur in this context, but there are more subtle possibilities as well.

I recall a photograph of a female therapist taken by her male patient in a playful moment, which was later used in a chronicle of the eventual therapeutic disaster. I imagine this therapist luring the damaged child she saw in her patient and bringing his (and thus, her own) playfulness back to life in her misguided efforts to heal him (herself). Again, this was not true altruism, though it may have seemed like a quintessentially intimate experience. The therapist could not follow through, in real life, on the intimacy that her behavior seemed to promise and that the unfortunate patient took literally. The devastated patient later suicided.

The fact that each member of this therapeutic dyad may have, at the moment captured by the photograph, felt wonderfully close to the other obscures the deeper reality that the therapist's behavior was selfishly, not altruistically, motivated on the level that we are describing.

To summarize, there are two opposite modes of objectifying patients and their needs: "technical" limit-setting (to which, granted, there sometimes is no viable alternative) and boundary-losing "symbiosis." Between these there is a needle to thread: the hard work of remaining engaged and distinct. One tries to keep one's boundary, containing and processing one's own evoked affects while maintaining contact with the patient in order to help them in a parallel process. This very tall order is the concern of much of the modern psychoanalytic literature. Successfully done, it is altruistic, but the long-term payoffs -- money, status, gratitude (these first three are iffy), the exhilaration of mastery -- are far more abstract than the exemplary "hunk of meat" that rewarded our altruistic forebears for their efforts and presumably helped select their genes for dissemination.

It is no wonder that we so regularly fall short of this therapeutic ideal of engaged distinctness. Our behavioral genetics were designed for the earlier situation and are inadequate for the present one. We are trying to cross the ocean in a cardboard canoe. When we see that it is leaking, there is a strong motivation to jump ship and swim for shore.

Thus, viewed in the cold light of evolutionary theory, modern psychiatry, in both its psychopharmacologic and psychotherapeutic aspects, is often in the business of making new and better defense mechanisms to help us bearers of the human hunter-gatherer genome to cope with our unprecedented social situation. We psychotherapists, from whose ranks the boundary violators usually come, try to reconstruct an Eden that never was, in which altruism and its accompanying warm feelings can operate unfettered by the context of real community and real participation in one another's lives. There is a regressive longing for the world of the perfectly nurtured child here, which is why speaking of the fallen psychiatrist and patient who act this out literally seems apt. Acted out or not, the psychotherapeutic Eden provides a respite from the anonymous post-industrial culture outside the door, an Eden wherein patient and therapist alike feel heard and are seen as people of individual worth rather than objects manipulated by market forces.

Meanwhile, psychopharmacology and the more directive sorts of therapy (those that correct "irrational beliefs") are busy building a different kind of Eden in which, if you can't be one of the few at the top of the modern dominance hierarchy, at least you can have (with our assistance) approximately the same balance of neurotransmitters. A selective serotonin reuptake inhibitor can do this for you directly, or a "corrected" cognitive schema of your place in the world can do it indirectly (but verifiably, according to before-and-after metabolic neuroimaging studies). Or, if society's demands remain beyond reach, perhaps stimulant medication can help you attain a more acceptable level of productivity, with the enhanced security and lifestyle options that accrue to those who can maintain it.

Myths can be life-giving at times, destructive at others. If psychiatry has any remaining potential as a socially progressive force, this Eden is one myth we need to lose. We must awaken from the unconscious thrall it still has over our professional lives in the form of unexamined assumptions and misconceptions about the work we do. In its modern psychiatric and psychotherapeutic versions, the renascent Garden of Eden myth now serves to distract us from consciously integrating our own discoveries about who we humans really are and how we really got here. It obscures the truths about modern life that impinge equally on those psychiatrists who succeed and those whose careers visibly go off course.

As responsible physicians we need, of course, to treat mental disorder, to prescribe medication, to perform psychotherapy. But our interventions are stopgaps, not solutions to the mismatch between our genetics and the culture we live in. Can we practice in such a way as to enhance our patients' perceptions about what is really going on in the social world? (Or validate those perceptions: in my experience, many patients see, in their own ways, exactly what is going on.) If not, we will remain in an ironic position: advocates of making the unconscious conscious, even as we unconsciously promise to do the impossible, or worse, act out the Eden myth with our patients.

Only in community does Homo sapiens have any chance of dealing with the evolutionary/cultural mismatch and its ubiquitously unrecognized consequences. We psychiatrists can begin to create community for ourselves as soon as we recognize that we are all fallen psychiatrists in a fallen world.