Unethical fantasies at professional dinners

I watched a man on stage today describe a case study where every intervention led to a measurable improvement in executive function. He spoke for forty five minutes about evidence based protocols and the importance of standardized assessment tools. He used slides with bar graphs that showed a steady decline in symptoms over a six month period. I sat in the third row and wondered if he actually believes his own data. Later that night, I sat across from him at a table in a steakhouse with three other practitioners. He drank three glasses of scotch and told me about a client he has seen for seven years who has never made a single measurable gain. He keeps the file open because the client pays the full fee out of pocket and the therapist needs to cover the tuition for his daughter’s private school. He admitted that he spends half their sessions talking about the local sports teams because the client is lonely and the therapist is tired. This transition from the stage to the steakhouse represents the actual state of our field.

The conversations that happen after the continuing education units are earned are a different species from the ones that happen during the sessions. I find more clinical truth in the third round of drinks than I do in any peer reviewed journal. The gap between these two worlds is not just a result of professional decorum or simple hypocrisy. This gap is a map of what the profession is afraid to look at. I am talking about the things I hear when the microphones are turned off. I am talking about the billing practices that stretch the truth until it snaps. I am talking about the diagnostic inflation that practitioners use to get an insurance code approved for a client who is simply grieving a divorce. These dinner table confessions reveal the structural rot and the human desperation that the official literature ignores.

I sat with a woman who is a prominent figure in the field of attachment theory. She has written three books on the subject of professional boundaries. She told me over a plate of expensive pasta that she has been in love with a client for three years. She does not call it erotic countertransference. She calls it a tragedy. She told me she purposely schedules this man for the final slot of the day so they can walk out to the parking lot together. She has never touched him. She has never broken a formal rule. But she uses her clinical knowledge to keep him tied to her emotionally in a way that prevents him from seeking a real relationship outside of her office. She knows exactly what she is doing. She also knows that as long as she uses the right language in her notes, no ethics board will ever find her. She is a master of the vocabulary of care, and she uses that vocabulary to camouflage her own hunger.

I see this pattern everywhere. I see practitioners who protect colleagues whose work is objectively dangerous. I know a man who has three active complaints against his license for boundary violations with female clients. He still gets invited to speak at national conventions. I have sat at dinners where people joke about his reputation. Nobody files a report. Nobody stands up in the business meeting to demand his removal. The cost of confronting him is too high for most people to pay. They would rather maintain the appearance of a unified professional community than deal with the reality of a predator in their midst. This silence is a choice. It is a clinical decision made in the interest of self preservation.

The financial reality of the private practice is another subject that stays off the stage. I hear therapists talk about their clients as if they are revenue streams first and human beings second. I have listened to a colleague explain how he convinced a client to stay in treatment for an extra year by subtly emphasizing the client’s lack of social support. He did this during a period when his own mortgage interest rate had spiked. He used the language of clinical caution to hide his own financial anxiety. He told the client that they were not yet ready to terminate because the client’s ego strength was still fragile. In reality, the therapist’s bank account was fragile. He turned his own need into a clinical diagnosis.

I am interested in why I feel more connected to these therapists when they are being dishonest than when they are being professional. The professional persona is a mask that hides the inherent mess of the work. The dinner table is the only place where the therapist is allowed to be as flawed as the people who pay for their time. I believe that the official version of therapy is a fantasy we sell to the public and to each other. We pretend that we are objective observers who follow a clear protocol. We pretend that our interventions are based on logic and science. But when the wine is poured, I hear the truth. I hear about the boredom. I hear about the resentment. I hear about the thrill of power that comes from knowing someone’s darkest secrets.

I once supervised a man who spent his entire career working with high conflict couples. He was a specialist in a specific form of cognitive behavioral therapy. He was brilliant on paper. In our private meetings, he admitted that he often chose a favorite in the room and worked to undermine the other partner. He did this because he found one partner more likable or more attractive or more similar to himself. He would use the techniques of the model to gaslight the spouse he disliked. He would frame his personal bias as a clinical observation about personality disorders. He told me this with a smile because he knew I would not report him. He knew that I understood the pressure of sitting in a room with two people who hate each other. He was offering me a piece of his reality as a way of asking for permission to be human.

This is the map of fear I am talking about. We are afraid that if we admit how much of the work is based on our own needs, the whole structure will collapse. We are afraid that if we stop inflating diagnoses, the insurance companies will stop paying us. We are afraid that if we name the incompetence of our peers, we will be next on the list. So we maintain the gap. I spend my days talking about growth and healing. I spend my nights talking about how much I hate a specific client’s voice or how I cheated on my taxes by categorizing a vacation as a research trip.

The professional dinner is a ritual of confession. It is the only place where the practitioner can acknowledge the absurdity of the “Diagnostic and Statistical Manual of Mental Disorders.” I have heard world class experts laugh at the arbitrary nature of the criteria they use to label children. They know the labels are often just a way to get a school district to provide more resources. They know the labels can follow a child for a decade. But on the stage, they defend the labels as if they were biological facts. They do this because the labels provide a sense of order and authority. The labels make the practitioner feel like a doctor instead of a person who is guessing.

I find that the most successful therapists are often the ones who are the most skilled at managing this gap. They know how to perform the role of the expert while remaining completely aware of the transactional nature of the relationship. They do not get confused by their own marketing. They understand that therapy is a business that relies on the continued suffering of the client. If everyone got better quickly, the business would fail. This creates an inherent conflict of interest that I am not allowed to discuss in a formal setting. I can only discuss it when I am sitting in a dark booth with a colleague who is also tired of the lie.

I am making the argument that these unethical fantasies are the most important part of our clinical education. They show us the limits of our models. They show us where the human element overrides the training. When a therapist admits they want to sleep with a client, they are revealing a truth about the intensity of the therapeutic bond that a textbook on ethics cannot capture. When a therapist admits they are bored to tears by a client’s repetitive stories, they are revealing a truth about the limits of empathy. These moments of honesty are the only thing that keeps the profession from becoming a complete sham.

I do not want more ethics seminars. I do not want more training on how to document my sessions for an audit. I want more of the steakhouse conversations. I want to hear about the mistakes that never made it into the case study. I want to hear about the times a therapist lost their temper and shouted at a client. I want to hear about the times a therapist felt a surge of triumph when a client’s marriage finally ended. These are the moments that define the work. The rest is just paperwork.

The gap between the public and the private is where the actual clinical work lives. It is the space where the practitioner has to decide who they are when no one is watching. Most of us are not the people we claim to be on our websites. I am certainly not. I am a person who has used my clinical skills to manipulate my own family. I am a person who has kept a client in treatment longer than necessary because I liked the way they looked at me. I am a person who has ignored a colleague’s obvious substance abuse because I did not want to deal with the administrative headache of a formal complaint. I say these things not because I am proud of them, but because they are true.

The profession is afraid to look at this because it would mean admitting that we have no special moral authority. We are just people with a specific set of tools and a lot of debt. We are trying to survive in a system that demands we be perfect while paying us to manage the imperfect. The dinner table is the only place where that tension is acknowledged. The clinking of the silverware and the smell of the scotch provide the backdrop for the only honest supervision we ever get. I will go back to the conference tomorrow. I will sit in the ballroom and I will nod at the graphs. I will applaud the speakers who talk about the formula for recovery. Then I will wait for the sun to go down so I can find out what is actually happening in those rooms. I will wait for the moment when the expert stops being an expert and starts being a person who is just as lost as the client. That is the only part of this job that still interests me.