Malpractice in psychodynamic psychotherapy – a retrospective case study

Abstract

A case of severe malpractice.

Full text

Malpractice in psychodynamic psychotherapy – a retrospective case study
Mika Turkia
mika.turkia@alumni.helsinki.fi, psychedelictherapy.fi, August 12, 2022
Abstract
This article describes a case of psychotherapeutic malpractice in Finland in the early 1990s. A patient in their early
twenties who had previously been hospitalized for a suicide attempt and extreme abandonment anxiety attended psy-
chodynamic psychotherapy sessions given by a female senior psychoanalyst for nine months. The therapist repeatedly
threatened the patient with abandonment, i.e. discontinuation of the sessions if the patient did not ’obey’ the thera-
pist’s demands. She repeatedly claimed that the patient had said something that the patient did not remember saying.
Her conclusions, based on the claimed statements, did not appear legitimate to the patient. Due to the resulting
uncertainty, the patient began to lose grounding in reality. In order to be able to ascertain what was real, the patient
eventually resorted to secretly recording the sessions and reviewing the recordings afterwards. After six months, the
patient concluded that the derealization was due to the therapist. The patient was afraid to confront the therapist and
announced the discontinuation of the therapy by sending a postcard. Official complaints by the patient led to only a
written warning being issued to the psychoanalyst by her professional association. There was no compensation for the
patient. The therapist continued psychotherapy practice for at least a decade. The details of the case were acquired
from written documents and audio recordings.
Keywords: psychotherapy, malpractice, boundary violations, ethics
Introduction
The case concerns the early 1990s but may remain relevant to the current day as educational material and an example
of severe misconduct, incompetence, and gross negligence.
In the early 1990s, Peterson noted that for centuries, medical professionals were assumed to be ’paragons of wisdom,
morality, and excellence’ but that such ’blind faith’ was fast disappearing (Peterson, 1992). She noted, for example,
that 5% to 13% of professionals in the mental health disciplines, medicine, and religion had engaged in sexual contact
with their clients. Recently, a study of 2500 patients in Germany indicated rates of professional sexual misconduct of
4.5% for female patients and 1.4% for male patients (Clemens et al., 2021).
Sexual misconduct is relatively easy to detect and understand. The present case demonstrates a more complicated issue:
malpractice by an induction of an almost psychotic condition. Especially in borderline patients, such outcomes may be
difficult to detect and prove. For example, Appelbaum has recently noted that ’claims based on alleged negligence in
psychotherapy are much more difficult to prove and, unless they involve boundary violations by the psychiatrist – such
as sexual activity with the patient – are unlikely to be successful’ (Appelbaum, 2021).
Linden has provided definitions for various types of unwanted effects of psychotherapy (Linden, 2012). Unwanted effects
include adverse treatment reactions caused by correct practice, malpractice reactions caused by incorrect practice, and
treatment non-response, which can be a result of either correct or incorrect practice. Deterioration of illness may or may
not be connected to treatment. Malpractice reactions are the direct fault of the therapist, who can be held accountable.
Differentiating adverse treatment reactions from malpractice reactions can be difficult due to the difficulty of determin-
ing whether the practice is correct or incorrect. Typically, the decisions are made by external ethical review boards.
However, to get to that point in the process, in the case of individual therapy, it is usually the patient who initially has
to be able to differentiate between correct and incorrect practice in order to initiate a regulatory process. This may be
challenging for patients with psychiatric conditions and likely impossible for patients with psychotic conditions. Fur-
thermore, the patient often has to persevere in the face of disbelief, prolonged bureaucratic processes, and various kinds
of ’cancel cultures’ that may exist in the healthcare system (e.g. patients’ complaints being ignored, or psychiatrists’
opinions overriding opinions of other medical professionals).
Lindgren and Rozental have noted that the nature of adverse events within psychotherapy and psychological treatment
has remained largely unclear (Lindgren and Rozental, 2021). They therefore analyzed 33 cases of suspected psychother-
apy malpractice in Sweden, noting that eight percent of all patient records involving psychiatric care described adverse
events that could have been prevented. The recognized general issues included lack of continuity of care (e.g. frequent
cancellations and rescheduling), lack of progression in the administration and implementation of care, lack of patient
Preprint; doi: 10.13140/RG.2.2.18960.07681 or 10.31234/osf.io/2pzjs; link: https://doi.org/mmf9

involvement in treatment choice and planning, compromised clinical routines (e.g. errors in patient records and diagnos-
tics), and lack of transparency regarding limitations of competence. Issues regarding therapists’ attitudes and behavior
included role confusion with transgressive behavior (e.g. self-centeredness, sexual invitations), negative attitude and
communication, lack of empathy, insincere or disrespectful advice, and a lack of collaborative stance.
The details of the present case were obtained from the original written documents and an audio recording of the
psychoanalyst’s final telephone call to the patient. Additional details about later developments were acquired from the
patient. The patient was also in possession of approximately sixty hours of recordings of therapy sessions, spanning a
duration of six months. Their contents were not further analyzed due to a lack of resources. The author did not find
previous documentation of similar cases. The mentioned psychotherapists had already passed away.
Case description
An unconscious patient was admitted to an emergency department after having attempted suicide by ingesting per-
phenazine that had been prescribed at an occupational health clinic due to extreme anxiety and a ’paranoid-like
surveillance of the reactions of other people’. An emergency department psychiatrist diagnosed a schizoid personal-
ity disorder (premorbid) (DSM-III-R 301.20) and a suspected atypical psychosis (DSM-III-R 298.90). Due to severe
malnutrition, the patient was initially admitted to an internal medicine ward for a week, and subsequently to an open
psychiatric ward for 2.5 months (the patient had not been previously hospitalized).
The patient had been in a relationship with a person exposed to severe, chronic domestic violence by their stepmother
since an early age. The person had subsequently been presenting with an intermittent suicidal psychosis. The patient
had been strongly attached to this person’s mother. However, the relationship had later dissolved, and this person and
the person’s mother had abandoned the patient. The patient suffered from extreme abandonment anxiety. Psychological
evaluation found severe depression, ’extreme defensiveness’, and ’paranoid-type projection’ (feelings of threat and being
under observation) but no obvious faults in reality checking. The patient was diagnosed with ’depressio mentis non
ultra descriptus’ (NUD; ’no further description’), as well as with a personality disorder with avoidant, dependent, and
compulsive features. Psychotherapy was recommended.
The patient was required to find a therapist by themselves. Eventually, a senior female psychoanalyst in her 60s, with
the highest training certifications in the psychoanalytic context, was found. Psychodynamic psychotherapy sessions
began four months after the discharge from the hospital. After approximately three months of sessions, the patient
began to feel extremely confused because the psychoanalyst repeatedly presented strong statements which contradicted
the patient’s autobiographical memory. She drew far-reaching conclusions about something she claimed the patient had
said in the preceding sessions. The patient could not understand this dissonance, and as the psychoanalyst insisted
that the reality differed from the patient’s reckoning, it became unclear to the patient whether the patient had become
’mad’ in some unexpected, incomprehensible way.
The patient described being unsure of what was going on and had not known how to describe or conceptualize the
situation. The patient did not expect anyone to believe that the highly trained senior psychoanalyst could not be
competent or reliable. The patient also did not trust the personnel at an outpatient clinic, had practically no contact
with parents, and had few friends, none of whom were experienced in such matters. In the end, the patient told no-one
about the situation.
Eventually, the patient resorted to attempting to get an objective view on the issue, and the only available objective
method appeared to be to secretly record all sessions on audio tapes with a recorder hidden in a bag. After six months,
the patient was able to conclusively ascertain the baselessness of the psychoanalyst’s claims. The patient eventually
realized that the psychoanalyst either did not remember what the patient had said, mixed the patient’s details with
details of other patients, or was in some way delusional. In addition to incorrectly citing the patient, the psychoanalyst
had also regularly contradicted her own statements.
The patient wanted to discontinue the sessions but was afraid to face the psychoanalyst, and sent the psychoanalyst a
postcard indicating a refusal to attend further sessions. The psychoanalyst called the patient on the phone the next
day. On an audio recording of the call provided by the patient, the psychoanalyst stated that the discontinuation of
the therapy had been done ’in a cowardly manner’. She demanded the patient return to the therapy. When the patient
declined, the psychoanalyst assumed it was due to the patient’s feeling of worthlessness. She said it was difficult to
understand why the patient wanted to end the therapy and that it was very counterproductive with respect to the
patient’s health. She repeated that the patient’s behavior was cowardly and that the patient could not remedy the
feelings of worthlessness without therapy: on the contrary. The psychotherapist said that ’in very rare cases, is therapy
as beneficial as in your case’ and that without therapy, the patient would only deteriorate.
The therapist asked whether she should give the patient’s scheduled appointments to someone else, or whether she
should ’still be graceful enough to let the patient return to the session the next day?’ The patient replied that the
psychoanalyst could take other patients. The therapist refused to believe that the patient would not return, saying it
was ’a highly desperate act: what has made you undertake this kind of an act?’ The patient replied that a debriefing
could be provided later, if necessary. The psychoanalyst refused such a debriefing but stated that ’it was an act of
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great grace on my part that I even called you. Are you serious or suffering from some kind of an episode? You have
no idea of what kind of harm you are doing to yourself. No idea at all’. When the patient asked, ’Do you still have
something else to say?’, the psychoanalyst responded, ’Yes. You need to return to the session tomorrow. No-one has
ended therapy in such a cowardly way’. The patient responded by saying, ’Someone has now’. The therapist repeated
that the patient didn’t understand, said it was due to the ’anger’ in the patient, and unilaterally ended the call.
The psychoanalyst subsequently issued a written statement to the Social Insurance Institution of Finland (KELA), a
state institution funding a majority of the costs of individual psychotherapy, with the patient paying a smaller portion.
The psychoanalyst’s statement contradicted her recorded statement that only in very rare cases was therapy as beneficial
as in the case of this patient. Instead, it stated that the psychoanalyst had doubted the usefulness of the therapy for the
patient already during the first week. The statement claimed that the patient had previously been treated by several
therapists (this was untrue: the patient had never received psychotherapy before, having only visited a youth outpatient
clinic a few times). The statement accused the patient of having criticized psychologists and of even trying to criticize
the psychoanalyst herself. The psychoanalyst further stated that the patient had made hardly any progress during
the nine months, adding that the patient was borderline, unable to see their own issues, only blaming other people,
including psychotherapists. According to the psychoanalyst, the cost-benefit ratio was unfavorable, and supportive
appointments with a nurse would have been more appropriate for this patient.
A KELA official later mentioned in passing that if the patient was unsatisfied with the therapy, there was a possibility to
file a complaint. The patient subsequently wrote an eight-page complaint letter to the national professional association
for psychoanalysts. The letter detailed the patient’s personal history and discussed in length the psychoanalyst’s
practices and attitudes. The psychoanalyst had regularly been late to sessions or had finished them early. She had
given the date and time for the next session only at the end of the previous one, making it impossible for the patient to
plan their life in advance. She had read her mail and painted her nails. She had routinely answered phone calls from
other patients as well as calls concerning buying or selling property; she had seemed to have invested in apartments on
a large scale.
The letter noted that the psychoanalyst had appeared ambivalent, with grandiose personality features, regularly ex-
plaining how competent and highly educated she was while criticizing her colleagues and any information not originating
from herself. According to the patient, the psychoanalyst had possessed a narrow vision of what the patient’s future
should be like, and she had presented strong criticism towards any plans of the patient that did not fit her vision.
The psychoanalyst had strongly criticized the patient for ’disobedience’, commenting, for example, that ’everyone who
has done what I say has done well but you express a strange defiance’. When the patient had been unable to read a
book required for an entrance examination, the psychoanalyst had commented that ’I don’t know what is wrong with
you since you can’t even read such a small book’. The patient noted that this manner of communication had been a
daily occurrence.
The psychoanalyst had expressed ’suspicions’ that the patient ’disrespected’ the psychoanalyst. She had categorized
her patients into an order of preference and informed the patient which behaviors were acceptable or required in order
for the patient to stay favored. When she had not been satisfied with the therapy session, she had refused to keep
previously agreed upon promises.
When the patient had questioned these practices, the psychoanalyst had replied that the patient was unreasonable
and had no legitimate reason to complain. According to the patient, she had regularly threatened the patient with
discontinuation of the therapy unless the patient ’behaved’ as she expected. She had not tolerated the patient talking in
an angry voice. When the patient had complained that her threats were exacerbating anxiety (the patient had initially
been referred to therapy due to an extreme fear of abandonment), she had intensified the threats.
The letter further mentioned that the psychoanalyst had expressed strong negative opinions against gays, feminists,
and men expressing feminine qualities. She had appeared obsessive, rigid, extremely defensive, and workaholic, seeing
patients approximately twelve hours a day, six days a week. The patient suspected that the number of patients was too
high to ensure proper care.
The letter described how the psychoanalyst had repeatedly stated that her political views adhered to the ideals of a
specific, already extinct, extremist authoritarian regime with a very violent history, originating from an Asian country.
The patient considered these views to be in a very strange contrast with the assumed values of psychoanalytic practice,
even more with the assumed values of psychotherapeutic practice in general, for example with regard to individuation.
The patient wrote in the complaint that the psychoanalyst had seemed to dislike, even hate, people with health issues,
including mental disorders.
Regardless, the letter noted that these examples of misconduct had not been the main problem: it had been the above
mentioned inconsistency with regard to facts, which had led the patient to a psychosis-like condition, which had mostly
resolved after the patient had eventually become conscious of the inadequate nature of the therapist-patient interaction
and discontinued the therapy. The letter noted that the threats had resulted in panicky fears and further deterioration of
the patient’s condition. The patient added that the psychoanalyst had seemed narcissistic, aggressive, and threatening,
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even sadistic. The patient concluded that it appeared that she was a danger to the patients, and it was inconceivable
that she had been allowed to continue the practice.
In response to the patient’s complaint, the national professional association for psychoanalysts required the patient to
visit another, male senior psychoanalyst three times to discuss the matter. The patient was required to pay for these
visits. According to the patient, this other psychoanalyst appeared quiet, fearful, and did not comment on the patient’s
claims.
As a part of a psychiatric evaluation about the patient’s ability to work, carried out at the Rehabilitation Foundation,
the patient also provided the complaint letter to a senior psychiatrist at the foundation. The patient later read in the
foundation’s statement to KELA that the psychiatrist had considered the complaints and malpractice claims completely
unfounded and inappropriate.
The patient also forwarded the complaint letter to KELA, which later informed the patient about the possibility of
making a complaint to the Finnish Psychological Association. In addition to forwarding this association the original
complaint, the patient added approximately two pages of more details. However, the association found out that the
psychoanalyst, who had a psychology degree and was a licensed psychologist, was not a member of the professional
association of psychologists. The ethical committee of the association considered the case important but stated that it
had no jurisdiction in the matter.
Later, a KELA official also mentioned that the patient could apply for a new therapist. Only two trainees with no
experience were available. The trainees refused to believe the patient’s description of what had happened, dismissing
the malpractice claims as imaginary. The patient could not form a trusting relationship with them and was left on their
own, without further attention from any party.
Seven months after receiving the complaint, the national professional association for psychoanalysts informed the patient
that they had issued a written warning to the psychoanalyst for indiscretion in therapeutic practice. Six months later,
the patient complained to the National Supervisory Authority for Welfare and Health, an office under the Ministry of
Health, which transferred the case to the provincial government. A month later, the provincial government stated that
the Act on Health Care Professionals (559/1994) had been introduced on July 1, 1994, i.e. after the treatment had
ended, and the provincial government thus did not have jurisdiction in the matter. Approximately a year later, KELA
informed the patient that the psychoanalyst had been declined the partial state funding for new patients. Regardless,
the psychoanalyst continued sessions with existing patients and accepted new fully self-paying patients. It remained
unclear whether KELA later restored the state funding for new patients.
The patient never managed to trust the healthcare system again. A handful of short-lived attempts at various types of
psychotherapy during the next decades failed.
Discussion
In addition to failing to adhere to basic ethical guidelines, it appeared that the psychoanalyst’s practices were inducing
a psychotic state in a patient who was already borderline. Interpersonal trust had been completely lacking. Especially
during the last six months, the patient had experienced the therapist as a threat, yet remained locked in the threatening
situation. With respect to Linden’s categories of unwanted effects, the patient presented with treatment non-response
due to incorrect practice (Linden, 2012). The patient also presented with malpractice reactions such as increased
symptoms and a loss of trust in the healthcare system.
The psychoanalyst appeared unable to perceive even the patient’s fear of her. In this respect, the psychoanalyst
appeared to have lacked even basic empathy and merely served as a caricature of a psychoanalytical endeavor assumed
to work with the subconscious. It remained unclear to the patient where the psychoanalyst’s extremist and violent
political views originated from.
With regard to the possible categories of malpractice identified by Lindgren and Rozental (Lindgren and Rozental,
2021), the psychoanalyst presented with each item in the attitudes and behavior category, i.e. transgressive behavior
(e.g. self-centeredness), negative attitude and communication, lack of empathy, insincere or disrespectful advice, and
lack of collaborative stance. Many of the general issues were also present. More worryingly, the psychoanalyst appeared
to have presented with unspecified, undiagnosed psychopathology. In comparison to the cases analyzed by Lindgren
and Rozental, the present case appeared to be more severe.
The handling of the case appeared inappropriate by even minimal standards. The national professional association
for psychoanalysts failed to ensure the professional competence of their members. After being informed of the severe
issues, they produced a minimal response that failed to ensure the safety of patients. They had also failed to forward
their decision to the Social Insurance Institution of Finland (KELA), which partially funded treatment of practically
all psychotherapy patients in Finland. An intention to hide the case could not be excluded.
Also, the actions taken by KELA appeared insufficient to ensure the safety of other patients currently in the care of
the psychoanalyst, as well as the safety of new patients. In the patient’s view, KELA officials had appeared ’confused’
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about the issue, commenting that the psychoanalyst’s statement had appeared ’a bit strange’ or ’somewhat unprofes-
sional’. The senior psychiatrist at the Rehabilitation Foundation had dismissed the complaints outright as baseless,
even ’inappropriate’. Two psychotherapist trainees had also refused to believe the patient. These responses indicated
a lack of competence in detecting and addressing malpractice. The only party who had seemed to show actual interest
in the case was the Finnish Psychological Association, which, however, had no jurisdiction to discipline psychologists
who were not their members.
The psychoanalyst had later refused to even admit having been issued a written warning; KELA officials had been
forced to provide her with a copy of it. In her communications to KELA, the psychoanalyst resorted to labeling the
patient borderline, which at the time was commonly equaled with being unreliable or ’manipulative’. The tactic of
questioning patients’ credibility appears typical in cases of ethical misconduct.
More broadly, these practices question the safety of individual psychotherapy. Unless there are objective documents
detailing what actually happened during psychotherapy sessions, a patient, especially one presenting with a psychotic
or borderline condition, may end up with no legal protection or rights. As suggested also by Lindgren and Rozental
(Lindgren and Rozental, 2021), possible solutions might include obligatory audio recording of sessions, which would
currently be technically trivial and feasible in terms of cost. Automatic speech recognition combined with artificial
intelligence-based text analysis could be utilized in data analysis.
Conclusions
The case demonstrated misconduct not only by an individual psychoanalyst but also by a professional society of
psychoanalysts, both of which appeared to attempt to downplay the case. There seemed to be little to no oversight,
little to no consequences, and no restorative justice, compensation, or remediation of emotional damage to the patient.
Patients rarely possess the resources or skills to conceptualize such issues or initiate regulatory processes.
Authors’ contributions: The author was responsible for all aspects of the manuscript.
Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-
profit sectors.
Availability of data and materials: Due to the protection of anonymity, the materials are not available.
Ethics approval and consent to participate: A consent to participate from the patient was obtained. Ethics pre-approval
does not apply to retrospective ethnographic studies.
Consent for publication: Informed consent from the patient was obtained but the patient requested a waiver of documen-
tation of informed consent (45 CFR §46.117(c)(1)(i)).
Competing interests: The author declares that he has no financial competing interests. Due to protection of anonymity,
competing interests related to personal relationships cannot be specified.
Author details: Independent researcher, Helsinki, Finland. ORCID iD: 0000-0002-8575-9838
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