On Sexualized Defenses, Transferences, and Counter-Transferences

Though I can remember almost none of my undergraduate professors at the University of Ottawa from the early 1990s, I have never forgotten Dr Arthur Blank, for both salutary and unsavory reasons. The salutary: I got to write a research paper in his Family Psychology class on what happens to families (such as mine) with a child who is chronically ill and then dies, and it was a profoundly revealing and helpful experience which earned me an A (not a grade I was anywhere near in my psychometrics or neurobiology classes that semester!), and gave me new and more sympathetic insights into what my parents faced and the choices they made to concentrate on my sister in the last six years of her life to the inevitable and unavoidable neglect of me and my younger sisters for most of our late childhood and nearly entire adolescence. 

The unsavory: a few months after class ended, he was in the papers on a regular basis being sued by former patients whom he had sexually abused in his private practice, including a woman who went into therapy with him to deal with having been sexually abused while growing up. He would be struck off the register of psychologists in Ontario and have to pay hundreds of thousands in damages to his ex-patients. I read the newspaper accounts with horror that a man could do such a thing to vulnerable patients. 

This coincided with living with a roommate, whom I knew slightly from my church (which very much encouraged his moving in), who had all kinds of issues with boundaries; we ended up having to ask him to leave. And it also coincided a few months later with my starting analysis and the great pains my analyst took to coax me onto the couch, which I was more than a little frightened of for the vulnerable position it places one in. ("What's she thinking back there watching me? What if she reaches around and touches me before I can see what she's up to and leap out of the way?")

Boundaries, then, have long been prominent in my mind. A few weeks back, I had occasion to read Glen Gabbard, "Lessons to be Learned from the Study of Sexual Boundary Violations" last week (American Journal of Psychotherapy 50, Summer 1996: pp.311-322). I posted insights from that on Twitter. He offers clear and concrete guidelines for avoiding boundary violations based on his work with more than 100 such cases. 

As important as his work in this essay is, he does not reflect on what might be useful in erotic transferences and counter-transferences and how to handle them in a profitable way that does not lead to disastrous outcomes. That crucial task falls to Andrea Celenza, Erotic Revelations: Clinical Applications and Perverse Scenarios (Routledge, 2014), who breaks the ice on these discussions (for me at least). As she notes, much of the clinical literature and likely almost all supervisory contexts avoid the topic because of the understandable fear and even shame such things evoke. 

I was not familiar with her work until Adam Rodriguez on Twitter mentioned how important her work is, and how she should be required reading in training programs. Having taken at least one lesson from her already, and used it in my own supervision, I would agree: she offers insights that begin a long overdue discussion, and we should be introducing that discussion to our students and supervisees. 

What do I mean by that? My take-away from her many insights is that there is a necessary difference between erotic attraction and sexual enactment, and that to feel and discuss the former without shame is not to necessarily risk the latter. Indeed, to put the point more strongly: perhaps the extent to which we feel more free to discuss erotic elements in the transference and counter-transference we may deprive them of the power of secrecy which so often masks and precedes boundary violations. Reading her book has in fact moved me along into feeling more comfortable discussing these things with my own supervisor, who has himself published on problems of sexual boundaries with certain populations, and discusses these with grace and good humour (not unlike Celenza's own supervisor as recounted in an hilarious anecdote on p. 69). 

The other crucial insight she offers is that sexual desire between patient and psychotherapist is always complex and complicated. Though Celenza is not so blunt on this point, I take her to be reminding therapists that if you think your patient really wants to just have sex with you in some straightforward manner, then you are deluded and have indulged in a self-serving and grossly reductionistic attempt to focus on only one thing: your desire. In this monomaniacal pursuit, you not only take your eye off the patient and his or her welfare, but you also fail to recognize that the patient's putative desire for you is highly ambivalent and complicated by many factors, and most certainly does not mean what you want it to. 

She puts it more elegantly and less compactly throughout the book, noting, first, that "being multiple selves is the human condition, and being multiple others to our patients is the analytic condition" (p.62). This multiplicity of self-states comes up several times in the book, and puts me in mind of a wonderful essay by Phillip Bromberg, "Standing in the Spaces," that I read recently and profitably. 

She continues in this vein, arguing, second, that "the gender that the analyst is...is not necessarily the only gender the analyst can be in the erotic transference" (ibid). I found this very revealing, opening up a new way of trying to understand same-sex erotic transference which baffled me in one particular case.

So the patient--whether male or female--could be responding erotically to us in a more maternal or masculine, or paternal or feminine role, or mixtures thereof; they could be responding from a younger and more childish part of the self, or (in our counter-transference) we to them from such multiple and entangled and ambiguous self-states of our own. Thus we see that the erotic response of patient to analyst, and therapist to patient, is not at all clear or straightforward, and responding as though it is will always invite disaster. (Celenza notes in an offhand passage something that Gabbard goes into in more detail: sexualized boundary crossings often happen when the therapist is engaged in "defensive efforts to manage our self-neglect" [p.67, with a reference to her 2007 book on the topic].)

Third, she states a little later that "the wish to know the analyst sexually is invariably complicated and usually highly conflicted. And if it is not, it should be, given the inherent power imbalances" in the therapeutic relationship (p.79). This theme of power imbalance is one she threads throughout much of the book, noting that it is inevitable no matter how much some misguided efforts might be made to flatten things and to insist patient and clinician meet on equal terms. We do not, and never will. 

I remember almost nothing else from one of my first supervisors, but he made damn sure to pound into my head one crucial point: We are not and never will be friends with our patients. A fortiori, we are never going to be lovers, either. As Adam Phillips says in one of his many wonderful books, psychoanalysis welcomes exploration of any and all topics no matter how emotionally and erotically laden and we can do this only because we agree never to have sex with each other.

On the question of sexual desires and their conflicts, I think the crucial passage in the entire book is this:

What do our patients want? They say they want our love, or more pointedly, to have sex--but do they really want that? We are many things to our patients simultaneously and equally important: analyst, woman, person, mother, father, sibling, and child....At any one time a plea for love or sex is a plea from within only one of those dimensions....The man may want a kiss, but the child does not. 

From this she follows up even more directly, insisting that "our patients do not really want us to gratify their erotic wishes, despite their vociferous protests to the contrary. But they do not want us to simply maintain our professional role either" (p.68-69). 

How, then, ought we to handle such things if it seems we are caught on the horns of a most serious dilemma? I confess I was gratified to read of her approach, which I stumbled upon myself before I had heard of this book. Celenza notes that if we cannot indulge patient desires, nor shut them down in a brutally "professional" way (for both responses harm patients in different ways), what is needed of us? Patients need us to respond to them as human beings, and so she said that sometimes a response like "I would if I could!" or "In another time or place" are just the sorts of responses "we need to convey to our patients" (p.69). (Quoted in this way, it may sound like Celenza is a bit flippant about such matters, but the force of her cogent book is quite to the contrary: she has clearly thought about such matters in depth and has hard-won wisdom abundantly displayed throughout the book.) 

I do not want to suggest this book is only devoted to these issues. Its other riches include good discussions in ch.1 especially on overly restrictive ideas of gender and on the uses of sexuality as a defense mechanism. Ironically, sexualized defenses and behaviors can often be used to stave off intimacy--a theme she devotes the entire second part of the book to in her focus on sadomasochistic and perverse habits and enactments. 

That final section, on sadomasochism, explicitly draws on a book I have half-finished right now: Robert Stoller's Perversion: The Erotic Form of Hatred. Celenza picks up where Stoller (whose work was published in 1975 but still has valuable insights for me at least in clinical work with sex offenders) leaves off and gives us a nuanced and balanced assessment before concluding that in her view sadomasochistic enactments are problematic insofar as they may be attempts to destroy any "tolerance of dependency, vulnerability, and self-revelation" (p.114) and may participate in "dehumanization of the other" (p.109). She notes that too often sadomasochistic habits may exist as a "closed feedback loop in which repetition and sameness is substituted for creativity and growth" (p.100). She gives an encouraging case study of one such patient who was finally able, after intensive analysis, to move into a much freer and more loving relationship with a woman who became his wife.

Musings on Reading Ogden

It was Adam Rodriguez on Twitter who convinced me to finally start reading Thomas Ogden. (At his recommendation I ordered Coming to Life in the Consulting Room and Rediscovering Psychoanalysis.) It is he who has further tempted (not convinced!) me to proffer, as he put it, some "primary process associations" in response to reading two of Ogden's books. This tempting invitation of his came in response to my saying I felt I needed to let these books steep for a few weeks or months, keeping silent about them. 

But, longing for a break from the tedium of marking nearly 100 mid-terms and essays, I decided to try to flesh out some reactions to Ogden. 

I am increasingly of the view that one is not ready for certain books until a certain time, which time may not be clear for many years, during which books will be attempted and abandoned. One is, moreover, going to read books differently at different periods of one's life, finding in some periods riches in the same books that were overlooked or unimportant on previous attempts. I've had all these experiences on several occasions. Perhaps the clearest recent example is finally being able to read some of Bion. I first learned of him from Nina Coltart, whom I started reading nearly 30 years ago, and to whom I now go back to regularly. Re-reading her is a wonderfully steadying but at the same time refreshing experience, not unlike re-reading Freud. 

Through Coltart, I quickly found my home in the British object relations and so-called Independent/Middle schools, where Bion looms large. But I simply could not make head or tails of the man until about two years ago, when his "Attacks on Linking" and his work on psychosis have proven extremely helpful in clinical work with both schizophrenia and an increasing number of cases of cannabis-induced psychosis. It was only after I started seeing psychotic patients that I could finally understand, almost all at once, what Bion meant by attacks on the links in the patient's mind, between objects, and between patient and psychotherapist. 

I tried, in a similarly desultory fashion, to read Ogden over the last few years. Given how many books he has published, I counted him a substantial figure and thought perhaps I might, some years hence, finally have time and feel inclined to tackle him, but his style, so far as I experienced it in one or two essays, rather put me off. 

Now, however, I am trying to rationalize blowing my remaining book budget for the year to buy all of his books. How can this be?

Firstly, the other clinicians I have found on Twitter have emerged in the last few months as a wonderful community from whom I continue to learn so much, and for whom I am so very grateful. So I trusted Adam's judgment enough to buy two of Ogden's books but then they sat on my shelf for a bit because I was uncertain of whether to begin them now or wait until I get some of the other half-dozen (at least!) books I have on the go finished first. Perhaps, I thought, Ogden really deserves to wait until the Christmas break when I'll have a bit of a clearer head. 

Once again clinical experience interposed itself and all of a sudden I dove in and read both Ogden books within a few days. It was a totally unexpected session with a patient that so deeply rattled me as to crack open some unexpected interior space to read and appreciate Ogden now. 

It was going to be a long five days until supervision the following week to process the session; but in the meantime--awkwardly, my super-ego evenly hovering with ever-attentive guilt at the ready for doing this because I have so many papers to mark and other books I should be finishing first--I found myself at first dipping into and then devouring Ogden's chapters in which he seems almost cheerfully to recommend doing something strange and admittedly uncomfortable: to "dream" the patient and the session, and to present both as a form of "fiction" ("Analytic Writing as a Form of Fiction"). Doing so, he hastens to add, is not a form of falsification, but arises out of the awareness that in sessions without notes or recording (neither of which I do), how do you present what happened afterwards?  

So I "dreamt" the story of this session several times on the treadmill in the following days, and it was very helpful to my own churning and processing of a session which, I said to my supervisor, felt very powerfully and disturbingly like my mind had been invaded in an attempted colonization. My counter-transference images in the session were of my first (last, and only!) MRI some three years ago, which was a nearly unbearable (and equally surprising) experience of captivity. 

The day after this exhausting session, another one with a different patient, I now see, also predisposed me to keep reading Ogden, especially his essay "Destruction Reconceived: On Winnicott's 'The Use of an Object and Relating through Identifications'." (Ogden's essay is masterful and deserves a response of its own. Perhaps I shall return to it again another time.)

I have read, and recently closely re-read, that Winnicott essay, but for all the warmth and light I constantly find in Winnicott, his essay is cold comfort when confronted with someone's vast reservoirs of white-hot rage. I need less theory here than Winnicott offers and more case material to see things in action. (I'm only half-joking when I say that as the product of a Canadian WASP family, mild irritation was the only permissible emotion tolerable in public display.) 

Winnicott, however, offers little of that here. Ogden, however, is more intellectually helpful. But surpassing both in concrete clinical helpfulness, to put it frankly, is being rooted in my own psychoanalytic therapy. My analyst's work with me is firstly grounding me, and then making me a more useful selfobject (to use the one, and only, bit of Kohutian terminology I even pretend to understand) by helping me to discover and create a deeper and wider inner emotional range (she's used the image of a metronome with me once and it's stayed with me as unexpectedly charming) in a quietly stabilizing way that allows for my working with, and not being totally swamped by, e.g., the full-force gales of psychotic mania and great masses of sadistic rage (and much else besides).

But to return for a moment to Ogden, I take him to be helpful to the extent that he suggests that what is destroyed by the child or patient is an image or illusion of the parent or therapist, and being able to sort this out and maintain this understanding is the crucial task during such destructive phases. This essay is so rich and inviting I could say much more about it, but I am now mindful of how long and ponderous and secondary-process-like this is becoming! That was not my intent at all here. 

I fear I cannot but do that in my own way of using, and using up, objects, including especially books. Else why have this blog? If nothing else, blogging is an exercise in indulging my "object hungers" as Sheldon Bach so memorably put it.

To avoid doing more of that here, I think I will just turn Ogden into a Magickal Aphoristical Cannon, shooting out bits that powerfully resonated with me and recording my most immediate thoughts upon reading them:

From Coming to Life in the Consulting Room:

Ogden: "We must invent psychoanalysis for each patient" 

Me: What a relief to know he does that so I don't have to feel guilty about having very different styles with each patient.

Ogden: "It is disturbing to recognize that, despite ourselves, we tenaciously hold to what we feel to be destructive aspects of ourselves, our internal and external parents, and of our social system and culture."

Me: Exactly right. This is why Freud first grabbed my attention in high-school, and why, for all its controversy, I still think his theory of the death drive has unmatched explanatory power. 

Ogden: "In dealing with the aspects of self that have been buried alive, it is of the utmost importance for the analyst to respect the patient's defenses."

Me: Yes. This puts me immediately in mind of Auden's lines from his panegyric for Freud where he writes of how Freud

would have us remember most of all 
to be enthusiastic over the night,
     not only for the sense of wonder
   it alone has to offer, but also
because it needs our love. With large sad eyes
its delectable creatures look up and beg
     us dumbly to ask them to follow:
   they are exiles who long for the future
that lives in our power, they too would rejoice
if allowed to serve enlightenment like him.

Ogden: "When I find myself asking questions that invite secondary process thinking on the part of either the patient or me, I pause to wonder, what is it about the unconscious aspect of what is occurring that is frightening to me?"

Me: Q.E.D.

Ogden: "It is incumbent upon me not to introduce or join the patient in 'parent-blaming'."

Me: Exactly right, and so important to remember with my adolescent patients where sometimes creating and having an enemy we can both hate is just a little too alluring, and a convenient way for me to collude in keeping the hatred safely out of the room. 

Ogden: "Psychic health, to my mind, is a reflection of the degree to which a person is able to genuinely engage in dreaming his lived experience."

Me: I'd get in trouble if I tried this regularly. Most people seem, when I ask about them, to regard nocturnal dreams, if they remember them at all, as some colossal irrelevancy and bizarre waste of time. How can I get them to dream while awake, to dream while in the session, to be curious enough about their day or night dreams to try to remember even fragments of them? American cultural ideals of productivity and efficiency are never so destructive as here, when talking about dreams.

And now for some from Rediscovering Psychoanalysis: Thinking and Dreaming, Learning and Forgetting.

Ogden: "I view it as my role to create...ways of talking with each patient that are unique to that patient in that moment....Talking with patients in the way I am describing requires that the analyst pay very careful attention to the analytic frame."

Me: I'm glad to know I do not have to achieve some weird scrupulous idea of 'consistency' with every patient as though we are in some manualized horror show. I'm also glad he mentions the frame here as that is so important, too, especially with this kind of freedom to be creative in each session. Gabbard's writings, which I've been reading on the frame and boundary violations, are now firmly impressed on my mind along with Ogden's.

Ogden: "It is at all times...the analytic task of helping the patient to become more fully alive to his experience, more fully human." 

Me: Yes! The spirit of Freud and Fromm lives on, and never more necessary in an age of 'skills building' and 'outcome measures.'

Ogden: "The analyst's ability to speak with humility from the uniqueness of his personality, from his own 'peculiar mentality,' lies at the core of what I am calling the analyst's style. It must be apparent by now that style is the opposite of fashion; it is also the opposite of narcissism." 

Me: What a relief! I know this to be confirmed by other research that your own style, and personality, can be a strength. Also humility, which seems to startle and even upset some patients when you tell them quite sincerely you are not an expert on their life and your job is not to 'fix' or 'cure' them. The longing for a guru is so strong in some people it startles and repels me. Perhaps I should do a better job of trying to get them to explore their longing for an authority figure to fix them? 

Ogden: "The analyst's task is first and foremost to allow himself to experience the full emotional intensity of all that he feels in the here-and-now of the analytic experience."

Me: Easier said than done! 

Ogden: "For many years I have enjoyed washing dishes."

Me: So do I! I think it's partly the same reason I enjoy cooking: it's something manual, which is so necessary when you're an academic and a clinician dealing with texts and abstractions and the unconscious world so much of the time. 

In conclusion, I've found Ogden a delightful writer in whom one finds much freedom to think and move. Doubtless I'll be returning to him again another time. (In fact, I had a recent relapse with my Visa card and two more Ogden books are arriving here Monday morning....)