Making Contact: Leston Havens on the Uses of Language in Psychotherapy

People for whom I have very great respect, and from whom I have learned and continue to learn much, have said very laudatory things about Paul Wachtel's book Therapeutic Communication: Knowing What to Say When. I have read it twice, and recommended it to students and interns albeit diffidently because I was sure I must have missed a great deal in the book because of my general dimness, laziness, or both. 

And yet, on both readings--three years apart--it has struck me as unnecessarily dense and prolix, needlessly complicated in places, and in want of more ruthless editing. The writing style is also entirely forgettable--it has little charm and even less humour. Does it have valuable things to say? Without doubt. Have I learned from it? Certainly. Does it fill a gap in the contemporary literature? Yes. 

But does it allow itself with some facility to translate memorably into clinical practice? No, it does not, at least for me.

Along comes a book treating the same issue but doing so in a way that is much briefer, written with greater cogency and accessibility, and occasionally has subterranean shots of sarcasm and the driest of dry humour, which we all know is the best kind. That book makes itself almost immediately clinically useful: it is by the late Harvard psychiatrist Leston Havens, Making Contact: Uses of Language in Psychotherapy (Harvard UP, 1986). 

Additional virtues abound in this book: the author name-drops almost never; his intellectual fireworks (as seen, e.g., in the use of jargon) are non-existent; the apparatus is very minimal and does not distract from the text; and he is that rarest of clinical writers in that his vignettes from sessions are usually a half-dozen lines at most. (I suspect I am very odd in finding it vexatious when clinical writers put acres and acres of session notes to illustrate one brief point. Others may benefit from this but I rarely do.)

The book consists of four chapters along with an introduction, the gist of which is that patients, being human, come in wearing disguises and leaving parts of themselves deliberately outside the door--absent, in effect, both consciously and unconsciously. Language has to find a way to outwit both of these phenomena. In order to find the other, the missing other, one employs the language of empathy, a succinct definition of which is given early on: 

empathy is best measured by the therapist's attempting inwardly to complete the patient's sentences. The more closely the therapist can match what the patient then says, the closer he is to the patient (p.19). 

Empathy will get broken down into different types as Havens proceeds through the book. These will then need to be deployed at the right time depending on what the patient presents with, and where they are with you in treatment. 

I: Immitative Statements: 

One begins with these. Havens says they are sometimes called 'doubling' as "in psychodrama and work with children." They consist simply in the therapist "speaking out loud for the patient," especially one who seems very lost, depressed, or to have little developed sense of self. Examples (there are many others):

Issue:                                                    Statement:

Fear:                                                    "Where does one find the courage?"

Doubt:                                                "How can I decide?"

Depression:                                        "What hope is there?"

Dominated:                                        "I have no rights." 

The utility of such statements is that they do two things: they demonstrate that the therapist is with and understands the struggles of the patient, but the therapist is also at something of a remove or a distance, which is important especially early on treatment when trust is not yet fully established and having someone close may be threatening. As Leavens puts it nicely, "the goal is to comfort by our presence, not to startle by our prescience" (28). There are echoes of Winnicott here, it seems to me, in his well-known call for patience in the therapist: "It appalls me to think how much deep change I have prevented or delayed...by my personal need to interpret. If only we can wait, the patient arrives at understanding creatively and with immense joy, and I now enjoy this joy more than I used to enjoy the sense of being clever."

In addition to foreclosing on the ability of the patient to get there before you, untested empathic statements can also be an imposition, Havens says, in forcing the patient to feel what you are feeling or what you feel the patient should feel. Instead you must create room for the patient to feel how and whatever they do. Thus in response to a patient's memory of being forced to eat what he hated because his mother dominated him, Havens said "I have no rights," an immitative statement that, the patient later said, made him realize: Havens is like me, and he also wants me to have rights.

II: Empathic Exclamations:

a) Nonverbal Sounds:

Havens says there is a whole range of these from simple to complex. The simplest of them are not words at all, but "nonverbal utterances" or empathic sounds, which "form an important supplement to what is usually considered the language of emotion, namely facial expression" (42). In 1986, when Havens published this book, he could not of course have forseen the rise of telehealth where, especially on the phone (less so in my limited experience on video calls), such sounds become vitally important. 

I admit I was gratified to read this section because I have found myself rather unselfconsciously making a number of these sounds as a patient is talking. In my experience the benefit is that they do not interrupt or prevent the patient from speaking. They convey not just interest but indeed empathy, but potentially many other things as well. In Havens' words, empathic sounds typically convey "ascent, protest, contentment, outrage, or sorrow." He gives an example of a patient weeping: while acknowledging that sometimes he, too, feels like weeping, what he finds himself instead doing is uttering "brief, low cries." 

b) Adjectival Exclamations:

These are what he also calls "translation statements" as you translate into words the feelings in or behind the story the patient is telling you. Such statements/exclamations are by definition very brief:  

Pain:                                     "Terrible!"   or    "How awful" 

Joy or Victory:                    "That's wonderful!"

Shock:                                   "Good God!"

If the shock strikes the therapist especially strongly, Havens--anticipating something Fonagy would recommend decades later, as I noted here--says you should freely request "Give me a moment to take that in" (p.44). Fonagy says the same thing: when you lose your ability to mentalize, you need to pause the session until you can recover. I've done this several times, especially with borderline and manic patients, and it is very helpful. 

Additional benefits are to be found in using these statements and sounds, chiefly that they can outwit the patient's defenses. They can also "normalize" (my word) what often feel like illegitimate feelings or a great deal of ambivalence in the patient. This is often the case early in treatment--or sometimes well into treatment--when "that rough beast, its hour come round at last, slouches toward Bethlehem to be born" in your presence for the first time. The patient tells you something they have not uttered to another living soul, and have scarcely allowed themselves to think, or feel much about. 

I find this especially in those who have been abused as children and do not, on first telling, know exactly what they are feeling, and whether they have the right to feel anything critical, hateful, or rageful in response to the abuser, especially if that person is still a part of their life. To these I often find myself saying something like "No wonder you were pissed!" (I deliberately use that language after a patient has told me that "We weren't allowed to swear" or "We got into trouble for cussing." My doing so conveys, without drawing too much attention to itself, that such language is fine with me. More important, of course, as Havens recognizes, it gives legitimacy, often for the first time, to the inchoate rage and hatred now heaving into view. 

c) Complex Empathic Statements:

All the statements and sounds Havens lays out for us have the twofold job of getting close to the patient and seeing the world from their eyes but not crowding them out or making them uncomfortable by your getting too close. Such statements as

"No one understands"

or

"No wonder you were frightened" 

have a way of accomplishing this twofold task. A "no one" statement "reconnoiters the field of blame," Havens says, while "no wonder" statements clear it. 

"Wonder" statements are very powerful in several ways, the author continues. As I suggested above, patients may have very covertly allowed themselves only the slightest bit of wonder at what happened ("was this normal? Should I be feeling like this?"), before shutting it down. Your use of such statements legitimizes the wonder and brings it out into the open. "No wonder" statements, Havens says, are a "denial of denial." If the patient has denied himself the right to feel something, your saying "No wonder you hate him!" now allows him to begin doing exactly that--if he chooses. That is an additional benefit here: you are not imposing what you feel, or what some abstract standard of feeling might insist the patient feel: you give them freedom and room now to feel something previously heavily warded off. 

No wonder statments can later on be supplemented or even supplanted by what havens sees as stronger expressions of empathy: "It is natural" statements. 

d) Bridging Statements:

In patients who are "supine" or who have hardly been allowed to live or develop a robust sense of self by parents or other overly dominating figures, or who are so severely depressed that there is little life in them at the moment, or who are heavily conflicted by their conflicting feelings (here I think of patients with obsessive-compulsive personality disorder--not OCD--about whom see some excellent resources here) you need to use bridging statements. These allow you to share the conflict around conflicting feelings, to be ambivalent with the patient in his or her ambivalence. They also, as he says later in the book, function as a form of "noninvasive closeness in which the patient has someone present on his own terms" (p.85).

Again using military metaphors (as Freud did in one of his most important papers, "Remembering, Repeating, and Working Through"), Havens says that in such patients you are entering a state of civil war, and you have to form a "provisional government" to deal with on the patient's behalf: "the seat of governance is found in an unexpected place: the patient's reaction to his own behavior." Precisely to the extent the patient finds his own behavior baffling or terrifying you have material to work with. (Here I am mindful of later developments in motivational interviewing in which you "roll with the patient's ambivalence.") By wading into an internally conflicted patient, the therapist gives both sides permission to acknowledge each other and begin talks toward integration.

Bridging statements to use here include "God knows": 

"God knows you must have wanted to escape from them!" (This, he says, lends support to the desire to get away while also subtly acknowledging problematic ties of authority holding the patient back.)

Another version of this to use is "God forbid you should try to escape." This, of course, is spoken "sarcastically" (p.62). In uttering it, you come alongside the patient in her desire to escape and to tell off the domineering authority figures. 

e) Causal Extensions:

One should not--I hope this is obvious to seasoned clinicians--use questions to demand of such patients as above "Why didn't you leave?" Those are very counter-productive approaches. Instead, Havens recommends causal extensions:

"If I say 'Why didn't you call?' I am judgmental, inquisitive, and assume that the patient knows. On the other hand, if I say 'You must have had some good reason for not calling,' I put myself with the patient and extend that empathy investigatively."

The above is, he says, a longer version of "no wonder" statements, but it does more work and opens onto a potentially longer line of inquiry. 

III: Good Management:

Later in the book, having fully convinced us of the need for all of the above, Havens then "rights the balance," as it were, by introducing some contrary factors to watch for. (On the very last page, he will later speak of "disciplined passion" so that your statements of empathy are not "empty display.") Here he says--in something that made me think immediately of Nina Coltart's open advocacy of the therapist always operating in "two minds"--the therapist cannot just be a tap pouring out empathy constantly. "Therapists must cultivate attitudes sharply opposed to one another," he bluntly puts it, reminding us that we have to enter into the patient's world via empathy, but we also cannot be "taken in" too much by that, losing our distance, our neutrality, our abstinence, our ability to mentalize. (There is little of clinical utility in my thinking empathy requires me to hate the patient's alcoholic mother or abusive husband as much as she does.) 

Remember, Havens says: "the object is the establishment of a working distance" (p.95) and both parties in the room have to be aware of the other and at the appropriate (and sometimes changing) distance from each other. If you collapse that distance and space--if there is, in Ogden's well-known terms, no room for an analytic third--then one has to wonder if any real work is going to get done. What will likely replace the work is some extended collusion-cum-enactment, and whom does that help? 

The Therapist's Authority:

Maintaining distance and space, however, does not mean a retreat to a preserve of therapeutic authority. Finding the balance here is, Havens freely acknowledges, one of "exquisite difficulty" (p.103). You need to likely have a greater sense of authority at the start so the work can begin, but as it progresses you need to relax that so that the patient does not come to be dominated by you, but to discover more freedom with and through your work together. (Havens is preaching to my choir here for I have long had in mind Erich Fromm's insistence from decades ago that in time a therapist has to be abandoned precisely so the patient's freedom can continue to expand, even by "disobeying" the therapist.) 

On Being Wrong and Acknowledging It:

One way Havens recommends doing this--and I was gratified to find I've just sort of fallen into doing this myself long before reading the book--is by your "willingness to be wrong" (p.105) and your inviting the patient to share whatever they feel, including critical or angry feelings towards or about you. Of course, merely telling the patient they can do this often cuts little ice. Instead, the author says think of what you have to do with frightened children: you yourself volunteer to go up to the barking dog and pet it, thereby revealing to the child that it is okay to do so. (Merely insisting "Go on--he won't bite you! Pet him! Come on!!" of course rarely works and often makes the child more upset.)

Another way to do this (which I have done) is to begin a session with an apology. I had let a patient, on a provisional basis, do something in session for about six weeks that I would not normally have encouraged and do not allow others to do. It became a ritualized part of the session and I half-forgot that it was supposed to be provisional. One weekend I realized it had long outserved whatever modest purpose it had and was now proving to be harmful to our work together. So I began the following session with an apology for letting it go on so long and explaining how I thought it was hindering the work. This so startled the patient that I saw a completely different, much more playful and emotionally fluid side of them that day, and slowly, haltingly, without any further encouragement from me, they began to venture more independent thoughts in session, and to disagree with me. I was delighted.

Projective Statements:

Additional ways to do this are by means of "projective statements." These put the "therapist's fallibility forward first" and reveal an example of your "happy receptivity" to being corrected.

One way I have found to do this is by using some version of the following prefaces:

"I could be wrong about this......."

"This may sound really off the wall, but I'm wondering if....."

"I really don't know if this is the best word for it, but I can't think of another at this point." (This often gets the patient thinking for a better one, and very often it is better and we happily agree on it.)

Havens suggests the utility of these projective statements with erotic and loving transferences, and his example of how to handle these is extremely close to the way that Andrea Celenza (as we saw here) recommends: by saying "You love me and naturally want me to love you." That normalizes things and goes some way to balancing them. But then you follow up with "Would that I could! Would that work made room for them both!" (p.107).

Counter-Assumptive Statements:

The goal here is to shake assumptions without getting drawn into a long debate about them. (They are especially useful if you find yourself caught in what I would call the agonies of an idealizing transference.) In brief, you do this by taking the patient's expectations and then "throw a dash of salt on those expectations" (p.115). Such disconfirming responses might include (only well after a solid alliance has been established!) saying "Yes, I know: you're a real idiot." Here you are sarcastically siding with the patient's inner prosecutor and the shock of your sarcasm, if done well and at the right moment and in the right way, can jolt them out of agreeing with that prosecutor. (I have done this many times and can report that it is very effective.)

I will pass over sections on counter-projective statements and others in the interests of wrapping this up.

Idealizing and Mirroring and Loving:

Some of the richest material in the book, for me, comes in the last chapter, and here again I thought of work with OCPD patients in particular. This leads Havens to reflect on the place of ideals and the therapist's use of what he calls Performative Statements: "the power of performatives is based on the therapist's authority and on the patient's need to be loved. Such statements evoke and then transform the need to be loved" (p.162). 

Havens gives the example of a deeply conflicted patient with internalized hateful objects that attacked the self, inhibiting a healthy self-love. So Havens sided with the kind, gracious aspects of the patient he saw, and called those out for attention, affirming them. The very "performance" of such affirmation ipso facto strengthened the kindness in the patient and allowed him increasingly to love that part of himself to the point he did not need external affirmation of it after a while. (As he puts it later in the book, "the therapist who finds something to admire in the patient creates the state of being admired.")

Such admiration is needed above all in those patients the author calls "supine." But once admired and loved--and my experience confirms this--they discover some inner resources and strength, so that the need to be admired does not become prolonged or pathological, but leads to real and important independent growth in a capacity for love and corresponding decrease in self-hatred. 

In the End, Love: 

This leads Havens into a very important clarification in the book, worth quoting in full and ending this review with:

Freud's cure through love did not mean any happy result that might spring from the love of a therapist for his patient. Quite the reverse....The cure through love...depends upon the therapist's finding in the patient a quality that can be admired, hoped, or wished for. It is the 'recognition of a promise.'

Psychoanalysis and Homosexuality

This short new book, Psychoanalysis and Homosexuality: A Contemporary Introduction (Routledge, 2023, vii+164pp.) by two British clinicians, Leezah Hertzmann and Juliet Newbigin, is something of a useful handbook of (select) sources. It would be helpful to have on hand to refute those who still wish to criticize Freud and associate to him what are demonstrably later and far less felicitous attitudes towards homosexuality, which he never held. Such (often tendentious) criticism is rather tiresome and has long been known to be baseless by those of us who have actually read, and still regularly re-read, Freud (as I have done since 1990), either in German or in the authorized translation, or both. 

Hertzmann and Newbigin's book reads, in part, rather like a graduate student's lit review as part of a thesis requirement. The authors have provided decent lashings of (select) primary source material (always in translation, of course) farced not with scholarly analysis but rather with commentary of their own, which has its place. The style is admirably and immediately accessible and clear.

My hesitation with this book is threefold: first, it is never clear how they chose to pay attention to some figures and not others. It is never good to leave your readers guessing about your selection criteria. To my amazement, the radical views of Sandor Ferenczi (so much so that Freud himself, very "liberal" in his day on this question, was made uncomfortable by them) on homosexuality show up nowhere in this book.  It would have been good, at the very least, to have a look into Sandor Ferenczi: Reconsidering Active Intervention by Martin Stanton. Other important figures from that first generation--which, as a whole, was far more "liberationist" than their reactionary heirs in postwar America--are also overlooked. Why?

Second, the book attends in no significant way to significant historiographical issues in the composition and context of the texts they choose to include, and in those they exclude. I teach my history of psychology class every fall, and attending to how and why that history is written, and by whom--who is in, who is out, who does the choosing, and what are the subterranean currents to this choosing and composing we need to listen for with our third ear--is at least as important as any question of what was written. 

From this follows my third concern: the book pays insufficient attention to sociopolitical factors, especially in the United States in the postwar (=Cold War) period, where many of the developments we can now rightly deplore in psychoanalysis took root with a vengeance. Though these authors indicate a nodding familiarity with Dagmar Herzog's book Cold War Freud, they have not sufficiently integrated her arguments into this little book (or those of other scholars who are relevant here, including Todd McGowan and Paul Roazen). 

The problem--as Freud foresaw as far back as 1909--was that on questions of sexuality in general, America was a puritannical and hostile nation that could not handle his ideas. And this was confirmed after his death in 1939 and the end of the war in 1945 when American attitudes (many of them politically driven) towards many things argued by Freud were disastrously distorted or abandoned, including such things as the restriction of analysis to physicians (which he strongly denounced in The Question of Lay Analysis) and the rise of psychoanalysis as an ideology (the best recent book here is Adam Phillips, The Cure for Psychoanalysis) with orthodox beliefs and practices rigorously policed and enforced by training institutes that often existed in a state of excommunication from each other) rather than a method of treatment. Those institutes, of course, came to exclude homosexual candidates from training. 

Now, it is rightly objected--as I have objected in the past as both editor and reviewer--that one must not unfairly criticize authors for not having written the book the reviewer thinks they should have while overlooking the book they did in fact write. That would be a valid objection here if--again--we were given any sort of rationale for how this book was written, or what the purposes of composing this highly selective, almost idiosyncratic text were. It is certainly not a systematic or comprehensive history, but that does not deny its value and virtues, and the place it does fill as a very brief introduction to the topic. Scholars wanting a more thorough, searching, critical, historiographically sophisticated text will have to produce one themselves or wait for others to do so. 

Having offered such concerns, let me now end with some examples of the book's virtues. 

The third chapter does, in some ways, attend to postwar figures sometimes overlooked, including Sandor Rado who, with some of the Kleinians and others like Edmund Bergler, seem to have played significant roles in shaping views on homosexuality and trying to obtain a role in its "treatment." This chapter--drawing on Herzog--also notes (as more recent authors such as Andrea Celenza and Galit Atlas have done) that psychoanalysis as a whole became far less willing to consider the role of the erotic, in all its forms, and far more suspicious of it and intolerant of its ambivalences and ambiguities. 

The final chapter of the book is the richest, and here the authors turn again to the problem of the exclusion and suspicion of sexuality across the board in clinical work, noting--as others such as Celenza, Atlas, Maroda, and Gabbard have done--that most training programs deal insufficiently or not at all with questions of erotic transference and counter-transference, but that such questions are even more defended against when "the patient's sexual or gender orientation is different from that of the therapist" (p.133). Thus, they argue, one of the challenges going forward is to more fully recognize non-heterosexual forms of desire and how they show up in, and have an impact upon, treatment. 

Desire: An Enigma Wrapped In Riddles Inside Mystery

Introduction:

I learn such things on Twitter. 

I forget to whom exactly to give credit for introducing me to Galit Atlas and her book, The Enigma of Desire: Sex, Longing, and Belonging in Psychoanalysis (Routledge, 2016). It may well have first been Adam Rodriguez, but I know it was even more forcefully Taylor Zimmerman, whom I met with great delight in Indianapolis in April at the celebrated day with Jonathan Shedler. Over the coffee hour and in subsequent correspondence, Taylor strongly encouraged me to read Atlas, so I am grateful to him as to Adam. 

Atlas is the third person in an ongoing series of clinicians in whom I am finding much wisdom with regard to erotic dynamics in psychotherapy, especially in the transference and countertransference. The first of these was, and is, Andrea Celenza, about whom I first wrote here, and more recently here. 

She and Glen Gabbard are arguably the two leading scholar-clinicians writing on sexualized boundary violations in professional contexts, including clinical and clerical contexts. Given the power of their writings, and the fact these topics are almost universally ignored in all training programs, and even by licensed professionals, I am at the point now where I just flatly tell anyone who asks, and even more who don't, that they should buy all of Gabbard's books and all of Celenza's and read them. Were I in charge of training programs in this country for future clinicians of all sorts, I would absolutely make these two authors mandatory reading. 

Into this group I now can bring Galit Atlas, who writes in a different style and with a different focus than Gabbard and Celenza, but with them is still broadly in the field--hitherto often terribly overlooked or denied--of erotic dynamics in treatment. Her book, The Enigma of Desire, puts me in mind of another recent treatment by another psychoanalyst, Carlos Dominguez-Morano (whose utterly irreplaceable Belief After Freud should also be required reading, not least by Christians still talking bollocks about Freud), The Myth of Desire: Sexuality, Love, and the Self, which I have to go back and re-read. 

Right, down to business. 

Atlas on Maternal Erotics:

Atlas begins punchily enough in her introduction by arguing that "In treatment, adopting the role of a nurturing mother can function as the therapist's way to avoid the erotic material that emerges between her and the patient." This I take to be just another version of the important warning (echoed by Shedler, Maroda, McWilliams, and many others) that being too much of a "container" (Bion) or providing little more than a "holding environment" (Winnicott) will mean you ultimately fail your patient who is there because something is wrong and something needs to be changed, not merely contained. 

A second related warning follows from this later in the book (p.80): "our patients' traumatized self-states may collude with our own in order to protect the tender parts of the self, the other, and the treatment from damage by the aggressive parts." (This, of course, is reason #23689 for the psychotherapist to have had his or her own in-depth and intensive long-term psychotherapy, and to engage in regular supervision and consultation.)

Also early in her book Atlas makes plain her own debts to what she calls Kleinian mothers, who have led her to be able "to trust the mind to lead us to the most unknown truths and to believe that the ability to tolerate those tensions allows us to live and to love." She also mentions her debts to Laplanche and Kristeva, and Jessica Benjamin, especially this: "I do not believe we can definitely know what belongs to us and what belongs to our patients." 

This point, of course, puts one in mind of Thomas Ogden's celebrated notion of the analytic third, and of the inability, as he has also recognized, to know where the patient's experience ends and the clinician's begins. 

The Erotics of Writing:

There is a sensuous quality to Atlas's writing itself, not least in her case studies, which are presented here in ways that are less stilted and bloodless than one so often finds. That is to say, there is still a warm pulse in the people she writes about. 

Moreover, and more interesting for me who has long loved to write and cared deeply about the felicities and rewards of style, and who has often felt a flush of excitement in the exchange of ideas, she openly acknowledges that "While writing, I found myself...swinging from feeling overaroused and exposed to using ideas as a way to distance, process, and regulate" (p.30). Lest we miss the point, a bit later she quotes a famous 1989 paper of Ronald Britton in which he recounts a patient demanding: "'Stop that fucking thinking'!" From this Atlas deduces that "thinking is a form of the therapist's internal intercourse" (p.32). Just so! 

I can relate to that outside the consulting room, but also in, which she captures with equal candor: "I notice the movement between moments of sexual stimulation and arousal to use of theory....I believe we often experience the same movement as analysts trying to regulate ourselves and our patients when the erotic pervades the analytic space" (p.30). Guilty as charged! (If I find myself becoming very theoretical, or subjecting the patient to a lecture, than I know my intellectualized defenses have led to such an enactment, and, following Fonagy's counsel, I need to rewind the session back to the point where I was able to mentalize before the defenses were, uh, aroused.)

The Enigmatic and the Pragmatic:

The unique contribution that Atlas make, so far as I can see at this point, is her stress on what she calls Enigmatic and Pragmatic knowing. Much more could be said about this, but I don't want to give all of the book away, so suffice it for me to say that the enigmatic and pragmatic are tied to her dual understanding of the origins of, changes in, and different desires manifested in sexuality: "the erotic comes into existence when the sexuality that at the start was based exclusively on nourishment and satisfaction of hunger moves away from the functional and toward play" (p.41). 

Do not, she warns later, be too enchanted (as some of us who love Winnicott are inclined to be) by notions of play, for these, too, can be used to displace certain important things: "playfullness can be a seductive way to express erotic and aggressive contents...but it's important to note that it can also serve to obstruct erotic transference and countertransference" (p.81). Yes it can, as I've noticed in some sessions after the fact, and not without some chagrin! 

Sexual Longing and Erotic Manifestations and Their Dangers:

Her mention of the erotic obstructing transference material takes us back onto more familiar ground, also covered by Gabbard and Celenza, and then by David Mann, whose two books on the topic I began last weekend, and about which I will have a very great deal to say later (O lucky reader!). 

Rightly does Atlas note early in the book that "sometimes we underestimate how dangerous it feels to be part of a dyad." I try to remind myself of that at least a few times a week, and (for some reason) it always happens at the last turn of the corridor immediately before bringing a patient into my consulting room. In those seconds as I usher them in, I cast my mind back to the first time I ever met with a psychotherapist (a pastoral counselor as I recall) in my teen years (to discuss sexual matters, too!), and how anxious I felt: I try to get a feel for whether this person with me is also a bit anxious, which is an entirely understandable feeling for, as Atlas continues a bit later, "being a patient is a dangerous position" for the patient may feel "he is forced back into the powerless position of being a child to a seductive mother who penetrates and excites him, feeds him but also controls his food and will certainly abandon him, leaving him overexcited, humiliated, and alone" (p.37). 

Strong stuff! No wonder people on Twitter lose their bloody minds when you speak such thoughts aloud; no wonder my undergrads had a collective meltdown at the mention of any hint of anything remotely "erotic" in the therapeutic relationship; no wonder even licensed professionals shy away from these discussions at best, and at worst become amusingly and revealingly hyper-defended. 

Why would anyone submit to this humiliating penetration and abandonment? Later she notes some of its rewards: "Allowing yourself to be penetrated means embracing a more fluid structure that is based on unsolidified boundaries....This is not exclusively a feminine process" (p.69). Indeed not. 

Precisely my attraction to psychoanalytic thinking, starting with Freud, more than three decades ago now was because it seemed to be quite at home with the idea of the fluidity, the complexity, the ambiguity and ambivalence--the sheer messiness--of human sexuality. I have always been highly suspicious of anyone who wants to put it into neat boxes, or map it out on a linear continuum or Kinsey scale. None of us is ever "straight." 

Before going further, she reminds us that for many of us, we had (referring to Kohut) no "mirroring" of the erotic and sexual growing up: "sexual feelings are unique in that caregivers systematically ignore them and they are therefore unmirrored" (p.115). This will and will not show up in a variety of ways in life, and in therapy. 

For some this lack of mirroring can leave the terror of such feelings in place, and that is where you must begin in therapy: "are there ways to listen for, and to, the unique accents of the language of sex." And if those accents are ones of fear, then, nodding towards Bion, Atlas says that an early task of the second mind in the room is to help the first mind bear to think about those fearful desires and terrifying thoughts.

As you think about them, some of the difficulty of such feelings comes from the fact that "sexual longing presupposes a sense of loss and a hope of refinding." 

That refinding is not a straightforward path from infantile attachment to adult sexual longings. It is often much more complicated than that, and thus the clinician needs to proceed with due caution: "the secret psychoanalytic touch is always about tolerating the erotic in the room while not adding to the stimulus." 

Earlier, she notes that we can and probably should do more than that: "we try to hold the unknown darkness with them, tolerate the 'too muchness' of excitement, joy, horror, and shame." Later she will speak of the "suffering of pleasure, of the excess that the body and the mind cannot contain," to which some might give the name "lust" while others (here Melanie Klein) prefer to speak of "human yearning for an 'unattainable perfect internal state'." 

Enactments Made and Redeemed:

Atlas is making what seems to me a very significant advance on how we think about therapeutic enactments. That word is almost universally taken as a sign of danger and enactments seem almost always to be treated sternly. This mirrors, it seems to me, the early Freud and his unidimensional warnings about the dangers of transference and countertransference especially. Only after 1950 did we start to get some limited reflection on what positive things countertransference might contain, and only much later--that is, within the relational movement of which Atlas is a significant part--do we start to see people recognize that countertransference can often be a positive good and contain much valuable information.

Similarly, Atlas is, in the last section of the last chapter of her book, opening up new territory by arguing that enactments are not just "a return of past dissociated memories but rather as the threshold for the introduction of emergent ways of being, of an opening toward new relational possibilities" (p.150). Enactments thus "work toward the future."

They do more than that, as becomes clear in her attempted definition: "enactments may well be a central means by which patients and analysts enter into each other's inner world and discover themselves as participants within each other's psychic life" (p.150). This does not guarantee, of course, that all enactments will always have a positive outcome, but it does begin to help them lose some of their fear, just as we have overcome fear from a century ago of countertransference as a sign of an insufficiently analyzed analyst. 

A concluding word that reminds us of how demanding our vocation as psychotherapists is, for we "must straddle a paradox, always skeptical, questioning, seeking hidden meanings, searching for unconscious dynamics at play, the trailing edge, a hermeneutics of suspicion--while also, paradoxically, trusting unconscious process and surrendering to the continuous flow of the enactive dimension of analysis, relying on a hermeneutics of faith" (here referencing Ricoeur).

On Love, Eros, and the Perverse

Introduction:

Recently with my students, I began a discussion about transference and counter-transference in psychotherapy, including erotic transferences and counter-transferences. The class seemed to cleave into two: those who regarded the idea of any sort of erotic feelings arising, in either direction, as "gross"; and those who didn't see what the big deal was. I'm not sure by whose response I am more disconcerted. 

Part of the difficulty turns on the wide variety of meanings attached to the term "erotic." I tried, following the ancients, to expand upon it as something much wider and more vital than the merely sexual or, narrower still, the genital. I brought in Freud's notion of the libidinal and its close links in to the notion of both "life" and "love." This gained traction with the students and also frank relief among them. At last they seemed to find a notion they could relate to: the erotic as something that excites deep and wide interest, even "passion," as people often say today, without necessarily implicating them in some sordid desire for sexual intercourse with whatever/whomever this objet is. 

In talking with them, I was of course drawing on what I've written previously about what I have learned, and am still learning, from Andrea Celenza, especially in her vitally important book Erotic Revelations: Clinical Applications and Perverse Scenarios (Routledge, 2014). I drew on her work with my students in attempting to illustrate the polymorphous ways in which erotic desire can arise in treatment. As Celenza shows, such desire, far from being avoided as it almost universally seems to be today, can in fact be helpful--but it can also lead to disastrous outcomes if not handled well. 

On the strength of how much I had learned from that book, I recently bought another of hers: Transference, Love, Being: Essential Essays from the Field (Routledge, 2022). There are riches scattered throughout this collection, one of whose chief virtues is that almost every chapter is 3 or at most 4 pages in length. 

The collection begins by reflecting on the disappearance of the notion of love in psychotherapeutic practice. And that reflection itself begins by referring to Philip Bromberg's work, who really deserves (and will one day achieve) an essay of his own on here. When someone introduced me, last fall, to his essay "Standing in the Spaces," it effected a sea-change in how I conceive of my own mind and the notion of selfhood and psychic change. It also changed for the good how therapy was progressing with one particular long-term case that seemed to be bogged down. 

Since then, I have used excerpts from his essay in a number of classes, and in every case it has stirred up lengthy and fascinating discussion. 

Celenza says that the splits in the self, which Bromberg focuses on, can be helped by reconsidering and reintroducing the notion and practice of love, properly understood, in the therapeutic relationship. 

Disappearing Love and Hidden Sexuality:

Along with the disappearance of any notion of love in contemporary practice, Celenza, in this book and her other one, has pressed the case more relentlessly and compellingly than anyone else I have read about the disappearance of sexuality and the erotic, citing a word-count Fonagy did some years back showing that terms like 'relational' are all over the literature today, but 'sexual' and cognate terms have taken a nose-dive. This leads Celenza to claim that "there is an unmistakable desexualization that pervades psychoanalytic theorizing...., an erasure of the natural erotic and sensual aspects of intersubjectivity" (p.75).

Celenza, later in this chapter, speculates that perhaps this disappearance has someting to do with the fact that, understood classically, "Eros is described as the son of Chaos, the original primeval emptiness of the universe" (p.76). She does not elaborate the point but the suggestion seems to be that therapy is often difficult enough without (one imagines some bedraggled, overworked, underpaid clinician moaning) introducing further potentially destabilizing and presumably difficult elements such as the erotic.

But at what cost do we exclude such things? In later chapters, she returns indirectly to the theme saying that "we must have the full range of affectivity at our disposal" in order for us to "help our patients...experience the excitements and mysteries within themselves" (113). These excitements, she notes a page later, "include allowing sexual desire to be present in our countertransference." The point of doing so, she repeatedly notes throughout the book, is to serve the patient: "the more we can acknowledge what we feel at work with our patients, the better we do." (Her earlier book, Erotic Revelations, has helped me greatly in seeing that such feelings can be stirred up within us in ways that unconsciously and blithely ignore our cultured notions of "gender" and "sexual orientation.") 

The Perverse and Sadomasochistic:

The essays in the final section are the ones I gravitated towards the most for I have for some time been engaged in trying to understand manifestations of what she calls "the perverse," including sadomasochistic fantasies and actions of some patients.

Some interesting work has been attempted here over the years, but there seems to have been gaps in the literature. Robert Stoller's book Perversion: the Erotic Form of Hatred, from the mid 1970s, seems to have been one of the first major works in the area. The topic comes and goes across the decades. There was renewed interest in the late 90s on the "perverse," and I have to say that it was a great surprise to see my first analyst's work in this area cited in Celenza's chapters and notes. (See also this essay by Dr. Louise Carignan, whose winsome necrology is here.) 

Celenza brings much (not all) of this literature together in chapters 30 and 31, which I found the richest in the book. She begins, rightly, by trying to define terms, offering "a contemporary definition of perversion that reveals a form of psychic functioning as a quality of being toward others, toward one's body, or toward internal objects" (p.139). This differs, she says, from past definitions which were almost always entirely behavioral in nature. She continues: "I propose that a perverse internal psychic mode is one where affective embodied and pre-reflective self-experience is split off or dissociated." 

Chapter 31 is perhaps the longest and most helpfully detailed in the book, and continues on these themes. She explicitly reviews the past literature to see what she finds still useful, discarding the rest. She says that any new attempt at defining the perverse must abandon "phallocentric and heteronormative assumptions." 

What does perversion look like in action? She begins by arguing that "persons engaging in perverse scenarios are attempting to imagine a one-person universe" (142). The tracks closely with cases I have seen clinically.

From here she lays out seven "characteristics that define a perverse quality of being." These are:

• Constriction and Constraint
• Repetition
• Objectification
• Sexualization
• Desire to Harm
• Means/End Reversal
• Absence of Symbolization. 

Taken together, these are usually brought to bear in constructing scenarios and fantasies to manage anxiety, ward off danger, and maintain control. As Stoller put it, sadomasochistic fantasies are usually ones of triumph that at some level are thereby trying to reverse the traumas of the past. They have a dead and deadening, self-reinforcing nature to them; their objects are sexualized to turn threats into pleasure; and there is very little ability to play with them in a symbolic register. She very helpfully elaborates on all these points in some detail, and with clinical material--as she does in nearly every chapter. 

Overall, then, Transference, Love, Being is a rewarding collection and I continue to be grateful for having been led to Celenza's work.

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.