On Therapeutic Drift or: Coasting in the Counter-Transference

There are certain books which may meander for several hundred pages, but have a single, simple thesis easily summed up in a paragraph or less and easily remembered thereafter; and then there are complex books that use all of their many pages to advance multiple points or explore multiple sources and contain so much content that re-reading on several occasions is required to master it all. Irwin Hirsch's book Coasting in the Countertransference: Conflicts of Self Interest between Analyst and Patient (The Analytic Press/Routledge, 2008) is very much in the former category, and that is very much a virtue. 

Hirsch's book (xv+220pp) is of standard length but really does advance a simple point that merely recalling the title is enough to remind you of the force of his argument. And his argument, his point, is an absolutely crucial one still too little talked about in the clinical literature after a century and a quarter of psychoanalysis and psychotherapy: the avoidance by too many clinicians of raising, and maintaining sustained and necessary focus on, conflicted and unsettling topics in therapy because the clinician would rather "coast" than run risks of patients becoming (more) angry or leaving therapy entirely to avoid painful topics. 

He states his thesis with pellucid clarity and simplicity on p.2: the clinician "can be said to coast in the countertransference, choosing comfort or equilibrium over creating useful destabilization." A little later on he notes further that "the quest for personal comfort and equilibirum with each unique individual patient is always potent" (p.4) for one of several reasons: I can't bear their rage/sorrow/other uncomfortable emotion; I can't bear the loss of income; I can't bear the loss of company in my lonely life. 

Hirsch zeroes in on a point others have remarked on: avoidance of conflict is an understandable weakness of most people, but it is not so understandable, and certainly not so justifiable, in clinicians who know--and ought to know--that until and unless difficult emotions are grappled with in the therapy, the process of change is very likely to remain dormant, weak, and ineffective. In other words, the absence of useful destabilization means the absence of meaningful and lasting change. 

On this point, I am, in reading Hirsch, at once reminded of my first encountering Karen Maroda some time back and, before her, of the incomparable Nina Coltart. Both of these outstanding women, from whom I have been learning for many years now (as I noted here and here), and to whom I continue to repair regularly, remind us that we need to do a much better job harnessing our aggression in clinical work and using it in these difficult situations where the attractions of coasting peacefully and passively down the quiet canal, rather than venturing out onto stormier bodies of water, remain strong. 

Maroda first broached this topic, if I recall correctly, in her book Psychodynamic Techniques and then more recently in The Analyst's Vulnerability, which I wrote about here. The former book, I should note, is coming out next week with much fresh and updated material, and I am planning on reading it at once. 

But back to Hirsch. He notes that one of the most common refrains from clinicians justifying coasting is that "the patient is not yet ready." Oh I can confess I've dined out on that in two cases simultaneously for months! In one case, I did and do believe it was justified, and that the patient was too heavily defended against hearing directly and clearly about a very strong transference dynamic which showed up immediately upon intake and was a constant (a highly vexatious constant, I would add!) for many months. This was also, not surprisingly, the thing that had destroyed so many relationships across three decades and led to an acute sense of isolation and, on occasion, serious thoughts of suicide. His effect on me in session was so strong that I deliberately and I think justifiably avoided confrontation until I could be certain that my reactions to him were under careful control. (Winnicott's warnings against retaliation echoed in my mind constantly.) 

"Strike while the iron is cold" was very much my watchword here, and when I finally did start to unpack with him what he had been doing to me in the transference, and had been doing with friends and family for decades, we were able to have a much less defensive discussion and make faster and more straightforward progress than I ever thought possible. At the end of treatment, he thanked me for being the only therapist in decades of trying who was actually able to help him understand his actions and feelings and help him to change them. 

Another case at the very same time brought me up short. I had also been saying "She's not ready" about this patient, who one day confronted me about this very topic and my avoidance of it! She pointed out that I had not gone back to a very painful topic she had raised about 4 or 5 months earlier, and I readily agreed that I had not. She quietly asked why I had not, and I said that in my estimation it seemed that she was not yet ready and I did not want to press too soon or too hard into matters that, months ago, seemed very tender and almost unbearable. 

"But couldn't you have asked me if I was ready!?" Her question had a real scales-falling-from-eyes effect on me, and I realized at once that she was right and I was wrong: I had made an assumption--my confidence in which was about 75 or 80%--and that seemed sufficient to me that I didn't need to verify it with her: I was about 80% confident she was not ready and so I continued to allow us to drift quietly down the canal rather than risk choppier waters.

I apologized to her for my presumption, and sincerely thanked her for teaching me an important lesson about not underestimating a patient's strength or overestimating her reluctance to engage a topic without first using the simple expedient of asking her if she was ready!

The beauty of Hirsch's book is that he is able to point out our tendencies to drift and coast without at any point sounding like a hectoring or sanctimonious moralist. He illustrates the book with many examples of his own failings--but these, too, are told without any tone of that moral masochism Freud first recognized. So we can feel challenged and confronted, but gracefully, humbly, and clearly because of a heartfelt desire "to be more useful to patients" (p.51).

In the end, the problem with drift or coasting is not one that can be permanently eliminated in advance, and the elimination of it should not be a process of constant recrimination from our superegos. Instead, it requires regular work on all our part, session by session, to ensure we are not allowing this to happen, but being both gracious and realistic about it when we discover it is happening. And such vigilance is required because of the all-important awareness that "patients change less from theoretically biased insights and procedures than from new and unpredictable affective relational experience" with their clinician (p.113). The supreme gratification of this work, in the end, is in watching people change in long-sought and often difficult ways, and we should set our boats to sail vigorously in that direction rather than drifting about inhibiting the progress we all seek. 

Betty Joseph on Psychic Change

As so often happens, my friends on Twitter [some insolent rabble in the gallery: "He has friends?"] convince me finally to read people of whom I have been aware, often for decades, without having actually read their works. In this case, it was a quotation from Betty Joseph. Finding it compelling, I ordered, and have now read, Psychic Equilibrium and Psychic Change: Selected Papers of Betty Joseph, eds. Michael Feldman and Elizabeth Bott Spillius (Routledge, 1989).  

Joseph lived to nearly 100, dying just a decade ago after a very long clinical career in England. (A short biographical sketch is available here.) My first analyst in Canada was a Kleinian and I vaguely recall her mentioning Joseph at one point but I never investigated farther. 

The Hard to Reach Patient:

Like all collections, Psychic Equilibirum is uneven. It contains papers originally published as far back as the late 1950s. Every chapter is fairly brief and follows a standard format. I perused the table of contents and decided, after reading the editors' introduction, to jump around, beginning with the chapter that first grabbed me most strongly, viz., no.5, "The Patient Who Is Difficult to Reach." I have at least one such right now and whenever I read a chapter like this--or any chapter by clinicians citing their own case material--I always hope (surely I am not alone in this?) that what they describe will be exactly what my patient is like so that, at last, I can stop thinking and reading and wondering and working to figure out the treatment they need, and instead copy the example cited by this manifestly masterful clinician. Thus does one see the very real attractions of manualized therapy!

But, of course, my patient is at least 90% different from Joseph's. (And thus does one see the massive limitations of manualized therapy!) So I ended this chapter somewhat disappointed, to be honest, finding it only partially useful. (That is also true of much of the book: I found only 2 or 3 chapters particularly useful, but read all of them, and found threaded through each and every one a common theme, noted below.)

But then, trying (at risk of sounding pious or sycophantic, both of which I abhor) to reflect over the whole chapter by means of a kind of reverie, which 'method' I learned from reading the great Thomas Ogden, I put the book down and stared across the coffee shop and out the window to the river, and found myself focusing on nothing in particular but allowing my mind to range back over the entire chapter as it tried to weave in one case in particular. At that moment I came to a rather startling insight about what now seems to me a technical mistake or perhaps an 'enactment' I have allowed to happen. I was aware of what I was doing, and thought it justified, but now in light of Joseph's chapter I see differently.

What, in particular, provoked this small epiphany? There are three lines in the chapter that were bracing to me.

First, she begins by talking (as others I have read would later do--I think in particular of Christopher Bollas here) about those patients eagerly proffering "pseudo-cooperation aimed at keeping the analyst away from the really unknown and more needy infantile parts of the self" (p.76). That latter phrase--more needy infantile parts--especially struck home and inched me toward greater understanding of a case in which my countertransference imagery has been utterly plagued for months with nothing but images of my cradling my (adult) patient as a babe-in-arms. 

This first line of Joseph's I immediately linked up with a passage a few paragraphs later in which, continuing the theme, Joseph speaks of the really needy part of the patient needing "the experience of being understood, as opposed to 'getting' understanding" (p.79). That, of course, echoes one of her contemporaries, Frieda Fromm-Reichman, and the latter's famous observation that the patient needs an experience, not an explanation. Here I came uncomfortably close to a second acknowledgment of a near-mistake in a case in which I have sometimes found, in my impatience, doing what Joseph warns against: offering 'an explanation,' a thing, rather than an overall experience--and doing so prematurely, in a way the patient could not use at the time. 

In doing so, I am now rebuked not just by her, but also by a passage of Winnicott I have not always heeded. In "The Aims of Treatment" from 1962, he speaks of the necessity of "economical" interpretations, rightly warning that "I never use long sentences unless I am very tired. If I am near exhaustion point I begin teaching." In my case it's not just a moment of exhaustion but also sometimes of frustration which I have done a poor job of controlling. At such a moment I lapse into professor and academic mode, giving a paragraph-length explanation, an understanding, an interpretation: these rarely go over well. 

At the very end of the chapter in the third passage of Joseph that I found challenging, she advises that with patients hard to reach, we must keep our interpretations, our understandings, "immediate and direct" (p.87; her emphasis). In other words, she explictly says, do not offer some kind of historical explanation or interpretation, linking together themes or events from years or months or even weeks past: stick closely to what is going on in that moment in that session in your consulting room. Here is where (as she'll make clear elsewhere in the book) Bion is handy: abandon memory of past events and sessions, and a desire to escape the present moment, and instead plunge right in to your immediate experience of and with the patient, and they of you. (Bion's famously difficult and confusing counsel is examined in a bit more detail here.)

I admit this--discussing what is happening in the moment--was enormously hard for me to do for a time, but working with borderline patients has in essence forced me to do it. I remember very clearly the first time, with enormous trepidation, I attempted it and how it proved to be so pivotal to treatment. Once I figured out my own idiom for doing it after that, and became (in part thanks to my own analyst) much more comfortable with the risks I felt I was running in doing this, it has begun to flow more easily now. I think the key for me was once again Winnicott. In that most invaluable of essays, "The Use of an Object," he helped me to see that I could allow patients to bring their rage out into the open of the immediate moment and try to destroy me but that I would not in fact be destroyed. 

The Patient Addicted to Near-Death:

The other outstanding chapter in this collection is "Addiction to Near-Death." Here she refers to patients engaged in "a type of mental activity consisting of a going over and over again about happenings or anticipations of an accusatory type in which the patient becomes completely absorbed." (In my experience this is characteristic of certain obsessional-compulsive personality styles, about whose treatment I wrote in some detail here.) For such patients their "seeing of the self in this dilemma [as] unable to be helped is an essential aspect." 

As a Kleinian, Joseph mentions projective identification and splitting in every chapter, and here notes that the splitting characteristic of these patients is such that "the pull towards life and sanity" (p.128) is projected almost entirely into the clinician. (I have found myself in this position but, being an ignorant fool at least once a day, rather blithely told myself--here vaguely calling to mind some exculpatory aphorism of Yalom--that it was simply me being "the bearer of hope" until such time as the patient could be more hopeful.....except they never assumed one bit of that burden, and acidly disdained any expressions of hope!) 

Joseph returns to this later in the chapter, speaking in more forthright terms than in many other chapters as she speaks of this splitting, and the clinician taking up the role of one who is hopeful about and pushing for change, as being a "collusion" in which a "major piece of psychopathology is acted out in the transference." If you are put into this position of bearing the hope and desire for change then "the patient constantly is pulling back towards the silent kind of deadly paralysis and near-complete passivity" in significant measure to avoid having to recognize and deal with their own "ambivalence and guilt" (p.136). 

The "patient's apparent extreme passivity and indifference to progress" is based in part on, and heavily reinforced by, the fact that "the near-destruction of the self takes place with considerable libidinal satisfaction." These patients enjoy the "deeply addictive nature of this type of masochistic constellation" (p.128). At the chapter's end, she will return to this in graphic terms, speaking of the patient as having "withdrawn into a secret world of violence, where part of the self has been turned against another part" and where "this violence has been highly sexualized" (p.137).  

A word is here introduced by Joseph, giving an excellent definition to a term I first encountered I don't know where some time back: chuntering. The chuntering patient goes "over and over again in some circular type of mental activity" that consists of endless grumbling, complaining, fault-finding. Sometimes, however, such chuntering is silent: Joseph mentions those patients who, passively and silently, will destroy whatever you are doing, apparently listening to your thoughts but all the while mocking them with silent contempt.

Given such powerful libidinal rewards for their self-destruction, it is no wonder that working with such patients is going to be very difficult. Joseph ends this chapter with no clear or simple fixes, saying simply that "it is very hard for our patients to find it possible to abandon such terrible delights for the uncertain pleasures of real relationships" (p.138). 

Once more the only thing Joseph counsels is taking a "moment to moment" approach in the session, monitoring the changes in transference (which for her is never static, never fixed, never permanent, but a live thing, a dynamic, living, changing experience) and counter-transference.  As a result the same behavior can have a difference transferential import: Sometimes the patient may be engaged in what appears to be chuntering, but doing so out of real psychic pain at some legitimate thing they need you to know about; at other times they may be trying to drag you into a masochistic enactment. You need to get clear as to which is which, and these can even shift within the same session.

Finally: What is the Change We Seek?

If it is hard for these patients to change, which patients find it easy? For Joseph the answer is itself easy: none. Nobody finds it easy to change for we are all shot through with ambivalence and conflicting desires, and all our struggles--whatever they are--are bound up with our personality structures (a point so helpfully made more recently by Jonathan Shedler and Nancy McWilliams, inter alia). Our personality defenses, Joseph notes here, are "very tightly and finely interlocked elements" (p.193). To change even one thing is to risk a cataract of other changes, and thus to provoke multiple defenses at every step: this is the theme of Joseph's fourteenth chapter ("Psychic Change and the Psychoanalytic Process"), the last on which I shall comment. 

How might we define change? What are its hallmarks? Here Joseph is very reluctant to get into details or to over-promise. Indeed, throughout this book one gets the sense that she is in constant, unwavering control of her omnipotent and omniscient desires, never overpromising or indulging in messianic fantasies about dramatic changes. 

"Moment-to-moment shifts and change" in the transference is what we should be paying attention to, Joseph says, without much regard for anything outside it. If such changes happen, then we are permitted to "hope" that such are "eventually going to lead to long-term, positive psychic change. I do not think that the latter long-term psychic change is ever an achieved absolute state but rather a better and more healthy balance of forces within the personality, always to some extent in a state of flux and movement and conflict" (p.194). This last sentence, to my mind, sounds very much like Philip Bromberg avant la lettre. (This chapter was originally published in 1986, a dozen years before Bromberg's Standing in the Spaces, an outrageously rich collection I hope to finish and write about next week. Bromberg cites this passage of Joseph's on p. 272.) 

From here Joseph expands somewhat outward, first noting what Freud said about change ("where id was, there ego shall be") before adducing what Klein added to this, and then, in sum, writing that psychic change consists in "greater integration between ego and impulses, love and hate, superego and ego" and that as an analysand moves toward greater health, this will be seen in an ability "to bear both his love and his hate at the same time and towards the same person. His perception of human beings then becomes more real, more human....This step, or rather, minute series of steps, forward and backward, towards integrating love and hate, brings with it momentous changes within the personality." (This theme of taking up love and hate will find powerful expression in Glen Gabbard's book of that name.)

Such changes may be seen in a greater ability to acknowledge and not flee from "guilt and concern" for others as we come to "take responsiblity" for our "own impulses" and how we may have harmed or attempted to destroy the objects of our life. If we take such responsibility, "there opens up the possibility of feeling for and repairing the object. With this there is also relief and a deepending of emotions" (pp.194-95). All of these changes emerge, Joseph stresses again and again, not in grand Damascus-like moments of blinding conversion, but often in the very minute, moment-by-moment changes in the transference, where it all begins; and if it doesn't begin here, it will never begin. 

This is a humbling note on which to end, but a salutary one. If we are always looking for external affirmations and grand signs of change and progress, we may risk overlooking, perhaps even disdaining, the quotidian ones in the transference.  We need to be content eating bread and butter as a regular diet rather than lusting after prime rib every day. 

We also need to be comfortable recognizing that the mind, Joseph says in conclusion, is a scene of perpetual conflict--even when progressing in the 'right' direction. If we leave our patient pretending otherwise, even as they progress in change and grow in freedom, then we have returned them to a very primitive form of splitting which, to Joseph, is anathema. 

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).

Gabbard and Bejnamin on Love and Hate

Freud won the Goethe prize for his magnificent German prose. We do not seem to have comparable prizes (so far as I know) in English to award to psychoanalysts like the venerable Glen Gabbard, whose prose is cogent and crisp, and written in an accessible and admirably humble way. In a future world when justice is finally and permanently established, that is, when I am at last emperor of all I survey, I shall bestow a prize on him. Perhaps we might call it the BST Prize. 

Having, as you will see here and here, recently written of how profoundly helpful I have found Andrea Celenza on the challenges of erotic and loving transferences and counter-transferences, and the associated problems of boundaries, it is no surprise to find Gabbard, in Love and Hate in the Analytic Setting, to be equally valuable on precisely the same points. Indeed, Gabbard and Celenza have collaborated on these issues in previous publications.

What follows is less a systematic reflection on Gabbard (and, toward the end, Jessica Benjamin, whose The Bonds of Love: Psychoanalysis, Feminism, and the Problem of Domination I finished on the same weekend as Gabbard) and more a kind of "aphoristic plundering," as it were. I used to feel vaguely guilty about this method of reading (which I do not use all the time), but having been fortified by stiff doses of Winnicott, quoted lavishly by both Gabbard and Benjamin, I justify such a method to myself by saying I am "using up" both authors, consuming them as good objects, and they are manifestly able to survive this "destructive" consumption of mine. 

Gabbard on Love and its Limits:

Gabbard begins on a note that might seem commonplace to many but which, within the hidebound context of psychoanalytic schools-cum-ideologies, is startlingly rare to read: "No one theory had all the answers to the challenges we confront in clinical practice" (xi). With this one simple manumission, as it were, Gabbard frees himself to range widely and unapologetically over Freudian, object relational, intersubjective, Kohutian, and other analytic traditions, finding what is useful and leaving the rest behind--the very model of "plundering the Egyptians" (cf. Exodus 12:36) one expects, but infrequently finds, in scholars and clinicians alike. 

Chapters 1 and 2 went over well-trod territory (for me) in quoting Freud's famous line to Jung that "essentially, one might say, the cure is effected by love." Gabbard admires this but is also troubled by it, leading him, in the second chapter, to note that one common motive in choosing to follow a vocation to be a psychotherapist is that you wish to be loved and admired. This is fine, he seems to say, provided you come (as he will spend the bulk of the book doing) to grapple with how much "sadism and aggression are ubiquitous forces in love relationships" (p.43). 

You must, to be an effective clinician, not fall into the trap of assuming that love is all you need, for love never goes anywhere by itself: tagging along are always aggression and hatred, and your failure to recognize and deal with these can, at best, lead to stalemate in the treatment, and at worse destructive enactments of various sorts (up to and including sexual boundary violations, about which he has written definitively in several places, including here). 

Gabbard on Hate and its Purposes:

Hatred, Gabbard shows, has multiple functions. Inter alia, it can:

• organize the ego
• master rage and destructiveness to prevent them from getting out of hand
• "conceal longings for love and acceptance" (especially in the transference; p.47)

Why, we often ask, do we hate for so long? Why can we not adhere to the simple counsel, "let it go!"? Gabbard says that "to hate is to hold on to an internal object" which may have had some purpose, including maintaining some contact with that object which was and is better than no contact. Such contact cannot just be dropped by the patient alone: the ties that bind to the object, he argues, can only be undone via the transference. Once again, following Franz Alexander, we see that what we learn to hate in one relationship we can relearn to hate (less) in another, and perhaps even to love it (more). 

Gabbard sees"hatred as residing on a continuum." My crude attempt to illustrate his several points would look like this: on the mild end of the continuum we'd see attempts at control or "domination" (as Benjamin calls it); in the middle there would be preservation of the hated object, but with some sadistically inflicted suffering; and on the extreme end, we would find complete destruction of the object. 

Regardless of type, Gabbard repeatedly cautions the clinician against rushing in to change focus, or try to control the hatred, or urge the patient on to replace it quickly with "positive" thoughts or "happy" memories (or worksheets and breathing exercises one might add somewhat snippily). I have often felt the pressure to do so, but every time I have resisted such pressure it has turned out for the best. As he rightly reminds us, "with many patients the necessary depth of understanding is not reached until one has sat for a sustained period with searing hatred or painful longings" (p.65).

Gabbard reminds us throughout the book that we all have our own hatreds and propensity for aggression. We cannot, even as well analyzed clinicians, fool ourselves into thinking we are utterly incapable of such things. Thus, he seems to suggest, it should not be that hard for us to have empathy for the patient's hatred and aggression if they are relatively accessible within us. (He quotes Searles and often Winnicott on this point of having your own hatred and aggression close by.) If we do find those things hard to understand, then we have forgotten what Christopher Bollas said decades ago: "In order to find the patient we must look for him within ourselves."

No Collusion!

Gabbard reinforces an important lesson, especially relevant to work with teens or disaffected spouses, but in some ways to all of our patients and their diverse hatreds: do not collude in creating an extra-transferential object to hate together. A therapeutic alliance cannot be built upon having a shared person or movement or experience to hate. Remember: hatred and love always co-exist, and to indulge in one-sided and totalized hatred (of, say, your patient's spouse, boss, or parent) is to risk collapsing the analytic space, to destroy the therapeutic stage on which you need to be able to "play" with these things for the patient to move forward. 

How Special Am I?

At one point Gabbard says we must confront the tension inherent in this work: we can only be special to the patient by renouncing all other special relationships, including lover, mother/father, friend, etc.

I admit to finding this very helpful with certain cases from time to time which seem to evoke a very strong protective-paternal counter-transference (discussed weekly in supervision, I hasten to say!). Part of me wants to fill multiple roles for such patients, being special in a good 4 or 5 different roles they lack--but which I know I cannot play because doing so would actually be harmful. 

What I can do, instead, is make sure that this one role--that of psychotherapist--is done according to the best of my ability. Allen Frances, on one of his very valuable videos with Marvin Goldfried (some of which I have my students watch), says that at every session the therapist should ensure it is a memorable experience for the patient. Do not treat it as just an ordinary event because, he says, for some their appointment with you is the highlight of their week. Thus it is special for the patient even as I am not that special. 

Such tension is hard to maintain for some. Gabbard recognizes that the forbidden nature of the relationship can make it highly erotically charged. We might not even experience conscious erotic or sexual attraction to the person; but the fact that we operate inside the frame, with its restrictions on what and how we meet and work together, increases the desire some have for a deeper intimacy than is possible (or healthful). 

At the same time, however, erotic and sexual desires may not be the hardest to deal with. I admit I was rather stopped cold by Gabbard's claim that "Sexualization may also defend against feelings of love...,which are relatively more difficult for many analysts to acknowledge than lustful feelings" (p.91). I have never thought of that before, but in reflecting on it, especially in light of my own analytic therapy, I think I see the logic of this now.  

Gender Fluid Transferences:

Perhaps the most valuable thing I have learned, first in Celenza, and now in Gabbard, is that--as it were--the unconscious mind and its desires are not gendered in the ways we might consciously expect. Some of the transferences toward me have been baffling until reading these two authors who argue, as Gabbard does here, that "there is considerable gender fluidity in the roles played by both analyst and patient in the analytic drama, and if these are allowed to emerge without premature foreclosure, a variety of transferences may appear that involve both homosexual & heterosexual longings" (120). 

Thus, whether with male or female patients, and prescinding from their manifest gender and sexual identities, I can at times be mother, father, brother, lover, and many other objects in the transference. And my counter-transferences are not just what might be called "paternal" (this one seems the most obvious) but also (much less obviously) "maternal": on this latter point I am constantly reminded of how much the experience inside the consulting room is indeed a "holding environment" as Winnicott put it, a "container" as Bion called it, and how those contemporary-clinical experiences are not far removed from the primitive experience of being held and cradled as a child as one's upsets and unknown desires are contained by the soothing mother. 

Let me turn now from Gabbard to Jessica Benjamin. Her book The Bonds of Love is one I have found helpful in dealing with overly sadistic material in some patients. 

I will not go into the wonderful (I almost said masterful!) ways she spends the first part of the book going beyond the understanding of domination in Freud to bring in Winnicott and others. She very helpfully gets us past the rather narrow range within which Freud understood these concepts into a wider terrain from which we gain a broader perspective. 

Much of this is possible by returning to Winnicott on "The Use of an Object." There he famously outlined how objects can be used and are destroyed--but survive. Indeed, use and destruction are linked: they must be destroyed inside our minds in order to see that they can survive outside and beyond us. This is a necessary first testing of reality, and (unlike Winnicott) Benjamin says such a discovery of reality is not merely grim awareness, but can be joyful: the destroyed object has--I discover to my delight--survived after all. 

Benjamin says the utility of this experience lies in the fact it reminds us how interconnected we forever are to each other: "if we assume complete control over him and destroy his identity, then we will have negated ourselves as well. For then there is no one there to recognize us, no one there for us to desire" (39). In saying this, of course, what echoes loudly in the background is Winnicott's famous declaration "there's no such thing as a baby!" By that he meant that a baby is always and only an object-in-relation: to the mother, father, and others around it on whom it depends. 

This dynamic helps us understand relations between sadists and masochists. Both need each other to undergo but survive the experience. Both may arrive at love via the experience. 

For the sadist (and I must say Benjamin gives rather more attention to masochists: her attempt to understand sadists is much less developed), the "thrill of transgression and the sense of complete freedom" are tinged with "fear (guilt) that his aggression will annihilate her." Her survival, however, "creates for him the first condition of freedom." The survival of the masochist creates in and for the sadist a real feeling of "love." 

In turn, the masochist's "submission is ambiguous," Benjamin suggests. It is a "false self," that is a "compliant, adaptive self that has staved off chaos by accepting the other's direction and control, that has maintained connection to the object by renouncing exploration, aggression, separateness" (p.72). But in giving over to an experience of pain "in the presence of a trusted other who comprehends the suffering he inflicts," the masochist can find not just relief but also a form of love. 

There is something a bit too neat here, I must admit. But I have already inflicted my own form of suffering on the reader with this over-long reflection, so I shall rein in my sadism for now, recommending both Gabbard and Benjamin and their excellent books to those who are not familiar with them.

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.