As some of you may know, making progress with a patient with a pathological organization is slow and uncertain.Having dwelt on the disempowered patient, I turn now to what it is in the psychotherapeutic relationship that is powerful, but in the long term powerful in aid of empowering the patient. The therapeutic setting is designed to help the patient move off defensive and defiant stances about behaving badly. That is the point of the analytic frame and therapeutic neutrality. I have written at length about this elsewhere (Young, 1998), and it is available at my web site. What I want to say here is that the room, its furnishing, its stability, one’s demeanour, absolute confidentiality, the forms of abstinence dictated by professional ethics, e.g, refraining from physical, sexual or social contact –- all these are designed to facilitate speaking in an exploratory way about matters which it is difficult to reflect upon in ordinary life. Along with what the therapist says and how it is said, they constitute the containment that makes change possible, though in no sense inevitable. The therapeutic frame is a safe place to take risks, to regress, to confess, to repent, to embark upon acts of contrition. My language here is deliberately biblical, for I believe that people come to us racked with the kind of guilt and anxiety featured in the Old Testament. The ‘Introduction’ to this series of talks said, ‘Most clients come to therapy with some sense of incapacity or lack of agency in their relationship with others’. I agree, but behind and underneath that lie guilt and anxiety of a very primitive kind that it is appropriate to call psychotic. It is these debilitating, disempowering, disenfranchising forms of negative, sapping motivation in their inner worlds that we have to make it possible –- by means of how we are and how we speak –- for the patient to come to believe might be diminished. Being in a position to assist in this process is power, indeed, but it is the power of the caring parent, not that of the boss, bully, abuser, judge or drill sergeant. We will be seen as such figures in the transference, but our task is to bear the projections, to ruminate and detoxify them, to gently disabuse the patient of the belief that such figures are everywhere. It is a power to withstand the accusation that we are, after all, a reincarnation of their bad objects and to convey steadily that there are, if only to a degree, alternative ways of experiencing us and others. You might call this power ‘abstinent power’, since it is our job not to retaliate, not to shoot from the hip, not to react in the way they goad us into acting, thereby proving that they were right, after all, to cast us in villainous roles in the transference. I often recall the morning roll call sergeant in the television series ‘Hill Street Blues’, Stanislaus Jablonski. He would always end his briefing by saying, ‘Alright, let’s get out there and do it to them before they can do it to you’. That’s the antithesis of our power. We don’t do it to them even after they do it to us or accuse us of having done it to them. This is in the spirit of the first roll call sergeant at the Hill Street Police Station, Sergeant Phil Esterhaus. His daily parting shot was containing rather than inflammatory: ‘Now, let’s be careful out there’.
I want next to turn to some philosophical thoughts which underpin the way I have been speaking. We conceptualise what we do in terms of analytic or therapeutic neutrality, free-floating attention, non-judgmental listening. When I was first introduced to these ways of thinking in medical school they were presented as being analogous in the human sciences to value-neutrality and objectivity in the natural sciences. I have come to believe that this is not a helpful way of thinking about our work. My reason for this is grown out of debates in the history and philosophy of science that it would take too long to go into here, though I have done so in my other writings, e.g., an essay on ‘The Cussedness of Psychoanalysis’ (Young, 1996). Suffice it to say that recent work in the history and philosophy of science has shown that the concepts of objectivity and value neutrality in the natural sciences are not a secure foundation on which to erect our practices.When, in the scientific revolution of the sixteenth and seventeenth centuries, purposes, goals and values were banished from scientific explanations, to be replaces by the project of explaining everything in terns of matter, motion and number, it is not true that the value realm was successfully banished. It went underground and re-emerged in various guises, for example in the concept of function in biology and the human sciences (Young, 1993, 2000). Value systems also lie deep in the assumptions and terms of reference of scientific disciplines, research priorities and ideologies which validate some terms of reference rather than others. For example, you can get a grant to do research in the molecular biology of organisms much more easily these days than you can get one to do field studies of natural history. The molecular level is privileged. Similar, explaining behaviour in evolutionary terms or in terms of analogies to computers is much more highly rated that work on personality theory, while psychoanalysis is under heavy fire for not being objective enough, even though we have an increasing body of scientific research showing the efficacy of psychoanalytic therapy. Instead of basing our approach on the putative objectivity of the natural sciences I suggest that we base it on a concept of deep subjectivity. The concept of countertransference (for an extended history of this concept, see Young, 1994, ch. 4) refers to unconscious reactions on the part of the therapist to the material of the patient. But in the early days of psychoanalysis the attitude to such responses was that they indicated that the therapist was incompletely analysed. He or she needed more analysis so as to minimize such reactions, which were seen as failures of objectivity. There was then a period when various people, e.g., Donald Winnicott and Paula Heimann, brought up the subject again and argued that countertransference was the result of feelings projected into the therapist by the patient. They should therefore be attended to and then overcome, once again with the goal of reducing the incidence of countertransference. Others, however, took the opposite tack. I am thinking, in particular, of certain writings by Margaret Little and Harold Searles, who advocated that we always attend to the countertransference. This way of thinking culminating in a paper by a recent President of the British Psychoanalytical Society, Irma Brenman Pick, entitled ‘Working Through in the Countertransference’ (1985). She argued that at the very centre of the therapeutic endeavour what we do is to interpret our countertransference and that this activity, far from being a aberration and something to be got rid of, is the essence of the therapeutic process. The patient projects feelings into us, these evoke unconscious feelings in us, we ponder these, detoxify them and give them back as an interpretation which is offered as a helpful insight. The more ‘spot on’ the interpretation, the more it reaches the patient’s infantile psychotic anxieties and releases them from the grip of debilitating neurotic motivation.
I am persuaded by this approach, but is should be noted that in terms of power it places a huge responsibility on the therapist. He or she is entrusted with the patient’s projections, which are plunged deep into the therapist’s unconscious, into their craziest places, far from their rational, secondary process mentation. Resonance, empathy and identification rule here. We seek to bear and contain these evoked feelings and to make sense of what is happening to us as a result of the patient’s intrusions into our inner worlds. We are entrusted with their madness, their psychotic anxieties, and we help the patient by tapping into our own, which are then reflected upon and interpreted. The more extensive our emotional range, the more we can relate to in the patient’s material. The more restricted it is, the less help we can be. This, of course, is the point of an extensive and searching training analysis –- to enable us to reach the parts that ordinary introspection cannot reach. It is, you might say, the Heineken safari of our training and our continuing clinical experience, analogous to reaching the parts other beers do not reach.
I say again that we are hereby being entrusted with great power, but it is given in the service of empowering our patients. They place themselves in our hands and entrust us with their most infantile and primitive feelings. When a therapist abuses that power he or she is engaged in child sexual abuse. I mean this both symbolically and literally. The analytic space is an Oedipal space. The analytic frame keeps incest at bay, and the analytic relationship involves continually offering incest and continually declining it in the name of analytic abstinence and the hope of a relationship that transcends or goes beyond incestuous desires. Breaking the analytic frame, therefore, invariably involves the risk of child abuse and sleeping with patients or ex-patients is precisely that.The most important and charged area of the responsible use of the power with which the therapist is entrusted is sexual abstinence, and the greatest breach of that power and the most grave form of acting out is that of sexual relations between therapist and patient. There are various estimates of how often this happens. Somewhere between two and ten per cent of male therapists have sexual relations with their patients, and about two or three per cent of female therapists do. Martin Bergmann reflects on this issue in a very helpful way in his essay on transference love (Bergmann, 1987, ch. 18). He says,
In the analytic situation, the early images are made conscious and thereby deprived of their energising potential. In analysis, the uncovering of the incestuous fixation behind transference love loosens the incestuous ties and prepares the way for a future love free from the need to repeat oedipal triangulation. Under conditions of health the infantile prototypes merely energize the new falling in love while in neurosis they also evoke the incest taboo and needs for new triangulation that repeat the triangle of the oedipal state (p. 220).
With respect to patients who get involved with therapists or ex-therapists, he says that they claim that “‘unlike the rest of humanity I am entitled to disobey the incest taboo, circumventing the work of mourning, and possess my parent sexually. I am entitled to do so because I suffered so much or simply because I am an exception’” (p. 222). Such sexual relations may seem a triumph to the patient, but, as Freud eloquently observed, in the following extensive quotation,
It is, therefore, just as disastrous for the analysis if the patient’s craving for love is gratified as if it is suppressed. The course the analyst must pursue is neither of these; it is one for which there is no model in real life. He must take care not to steer away from the transference-love, or to repulse it or to make it distasteful to the patient; but he must just as resolutely withhold any response to it. He must keep firm hold of the transference-love, but treat it as something unreal, as a situation which has to be gone through in the treatment and traced back to its unconscious origins and must assist in bringing all that is most deeply hidden in the patient’s erotic life into her consciousness and therefore under her control. The more plainly the analyst lets it be seen that he is proof against every temptation, the more readily will he be able to extract from the situation its analytic content. The patient, whose sexual repression is of course not yet removed but merely pushed into the background, will then feel safe enough to allow all her preconditions for loving, all the fantasies springing from her sexual desires, all the detailed characteristics of her state of being in love, to come to light; and from these she will open the way to the infantile roots of her love (Freud, 1915, p. 166). From the therapist’s point of view, as Bergmann puts it, ‘When the transference relationship becomes a sexual one, it represents symbolically and unconsciously the fulfilment of the wish that the infantile love object will not be given up and that incestuous love can be refound in reality’ (Bergmann, 1987, p. 223). This is a variant on the Pygmalion theme. The analytic relationship works only to the extent that the therapist shows, in Freud’s words quoted above, ‘that he is proof against every temptation’ (Freud, 1915, p. 166). Robert Langs conveys this very well when he says that ‘the therapist’s appropriate love is expressed by maintaining the boundaries’ (Langs & Searles, 1980, p. 130).
Nevertheless, alarmingly many therapists do abuse power and trust and sleep with their patients. If the motives for abstinence are not sufficiently strong, the situation is perfect. There is opportunity in the therapy hour and on the analytic couch. There is no fear of interruption. The patient has placed herself in the therapist’s hands, under his care, trusted to look after her. In their omnipotent and incestuous way of seeing things, what could be a more tender and intimate way of doing so? When the transgression is discovered (usually when the therapist belatedly comes to his senses and the patient is infuriated by his rejection), the matter is frequently brought before a professional ethical committee, and the therapist is struck off, suspended and/or required to undergo further therapy. I know of a case where this was done twice with a training therapist and supervisor who took up the practice again and finally had to be permanently removed from the professional organization.
This is not a new phenomenon. It has occurred throughout the history of psychoanalysis and psychotherapy, indeed, throughout medicine and the helping professions. Eminent people have been involved — e.g., Carl Jung, Sándor Ferenczi, Ernest Jones — and there is a chapter summarizing the history of this matter in Gabbard and Lester’s useful book on Boundaries and Boundary Violations in Psychoanalysis (1995, ch. 5). Other forms of boundary violations abound. An eminent American analyst was discovered to have benefited his professional society to the tune of a million dollars from a trust fund of someone with whom he was involved clinically. Freud and Klein analysed their own children. Freud regularly reported to Jones about the progress of Jones’ lover’s analysis with Freud. In the early days of psychoanalysis some of these violations could be attributed to the teething problems of a new discipline, while more recent indiscretions cannot. It is an ongoing problem, and instances of it occur all the time, so much so that ethical committees exist in every training organisation and many other professional bodies. Since there is a tendency to sweep such matters under the carpet it has become necessary to set up independent bodies so that injured parties can be helped to make complaints and make them stick. In London there is POPAN, concerned with the prevention of professional abuse of trust. Most of the complaints to POPAN come from the patients of psychiatrists and psychotherapists.
In his book, Sex in the Forbidden Zone (1990), Peter Rutter makes the point that sexual relations should be taboo in any situation where one person is in the care of another, where there are disparities of power (Rutter, p. 26) or where expertise is involved or the conferring of qualifications. Sexual relations in such circumstances are, he says, ‘inherently exploitative of a woman’s trust’ (p. 21).
Under these conditions, sexual behavior is always wrong, no matter who initiates it, no matter how willing the participants say they are. In the forbidden zone the factors of power, trust and dependency remove the possibility of a woman freely giving consent to sexual contact. Put another way, the dynamics of the forbidden zone can render a woman unable to withhold consent. And because the man has the greater power, the responsibility is his to guard the forbidden boundary against sexual contact, no matter how provocative the woman (p. 25).
This taboo includes obvious cases such as doctors, therapists and carers (especially of children, people who are learning disabled or mentally ill), but Rutter also includes teachers, supervisors, dentists, lawyers, architects, bosses, higher ranks in the armed services. He points out that 96% of cases of exploitation in such situations involve a man as the one having the power and trust, with the woman as the person entrusting herself (p. 20). He estimates that in America about a million women have had their trust violated in this way (p. 36).
Disparities of power and patronage are not compatible with the equality and sharing needed for a good and wholesome sexual relationship. This is a stern doctrine and one that is often transgressed. Think of the number of doctors who marry nurses, of patients who marry carers, of couples who first meet in a relationship between professional and client. Some argue that such relations are acceptable after a suitable interval, one that is specified in regulations as, say, six months or two years. I take the view that this may be acceptable in some of the relationships listed above, but I think it is not true of the relationship between a psychotherapist and a patient. The transference never ends, so sexual relations will always be unconsciously incestuous.
There is a considerable literature about failures of abstinence between therapists and patients, extending from apparently small matters to sexual relations. In a number of cases which did not involve sexual intercourse, there was much breaking of boundaries. ’Ann France’ is the pseudonym of an academic who succeeded in bending many boundaries in her work with various therapists. In her account of there, Consuming Psychotherapy (1988), she advocates looser boundaries and more self-revelation on the part of therapists. Some time after writing this book she committed suicide. I edited and published her book and believe that although she was a very disturbed person, more boundary-maintenance on the part of her therapists might have averted this outcome. We will never be sure. (Herman, 1991, has commented on this case.) ’Sarah Ferguson’ is the pseudonym of another patient who, in A Guard Within (1973), gives an account of a therapeutic relationship in which her therapist saw fit to relax a number of boundaries. This patient also committed suicide. The distinguished psychoanalyst, Margaret Little, (1985) tells a surprising story in which her analyst, Donald Winnicott, regularly transgressed various boundaries when she was severely disturbed. More recently, Wynne Godley has told a lurid tale about his analyst, Masud Khan, who broke practically every imaginable boundary, including having social relations and sleeping with patients (Godley, 2001). Brett Kahr has looked carefully into Winnicott’s failures to maintain boundaries and the baleful consequences of his many lapses. I consider all of these to be cautionary tales: keep the boundaries.I know of a number of therapists and analysts who believe that friendship between themselves and ex-patients is appropriate. In all of the instances which I know enough about to feel entitled to express an opinion, I am sure that the relationship has had a bad effect on the ex-patient’s subsequent life. One analyst makes a point of keeping in touch with ex-patients, of becoming friends with them and having them bring their dreams to him. My view is that these people remain in orbit around this analyst to the detriment of their autonomous development and, in a surprising number of cases, to the detriment of their marital or partner relationships. Something similar occurs in patronage networks between therapists and their patients or former patients. In his book, Unfree Associations: Inside Psychoanalytic Institutes, Douglas Kirsner (2000) has written a detailed account of patronage relationships in several of the big American psychoanalytic societies. It is striking how the patients of some training analysts prosper in the organizational roles in those institutes and become training analysts in their turn. Something similar can be said of the wives of some senior training analysts: suspiciously often they seem to become training analysts before some unrelated colleagues. It may be merit; it may be nepotism. My view is that if you are someone’s therapist or analyst you had better not have any other relationship with them, and if you are someone’s partner, you had better not be involved in assessing his or her merit for preferment in a supposedly meritocratic organization. Analogous boundaries apply to relations with patients. I hope it is clear that the analytic frame, its maintenance and breaks in it and acting out are topics which closely interdigitate with the topic of power, and that there is an ongoing relationship among these matters throughout therapy and ever after, as long as ye both shall live. The danger of abuse of power is the negative side of the appropriate use of power and the granting of trust in the intimacies of the unconscious and conscious communication between patient and therapist which lies at the heart of successful psychotherapeutic work.
Talk delivered in CONFER series on ‘Power in the Clinical Relationship’, London 25 November 2002. I have drawn to some extent on my other writings.
(Place of publication is London unless otherwise specified.)
Bergmann, M. S. (1986) ‘Transference Love and Love in Real life’, Int. J. Psychoanal. Psychother. 11: 27-45; reprinted in his The Anatomy of Loving. Columbia pb, 1987, pp. 213-28.
Brenman Pick, I. (1985) 'Working Through in the Counter-transference', Int. J. Psycho-anal. 66: 157-66; reprinted in Spillius, ed. (1988), vol. 2, pp. 34-47.
Ferguson, Sarah (1973) A Guard Within. Chatto & Windus; reprinted Harmondsworth: Penguin, 1976.
France, Ann (1988) Consuming Psychotherapy. Free Association Books.
Freud, Sigmund (1915) ’Observations on Transference-Love (Further Recommendations on the Technique of Psychoanalysis III)’, in The Standard Edition of the Complete Psychological Works of Sigmund Freud, 24 vols. Hogarth, 1953-73. vol. 12, pp. 159-71.
Gabbard, Glen O. and Lester, Eva P. (1995) Boundaries and Boundary Violations in Psychoanalysis. N. Y.: Basic Books.
Godley, Wynne (2001). ‘Saving Masud Khan’, London Review of Books. 22 February, 3, 5-7.
Herman, Nini (1991) ‘Prodromal States of Suicide: Thoughts on the Death of Ann France’, Free Associations. (no. 22) 2: 249-58.
Hyatt Williams, Arthur (1998) Cruelty, Violence, and Murder : Understanding the Criminal Mind. Karnac.
Kahr, Brett (in press) ‘Masud Khan’s Analysis with Donald Winnicott: On the Hazards of Befriending a Patient’, Free Associations.
Kirsner, Douglas (2000) Unfree Associations: Inside Psychoanalytic Institutes. Process Press.
Langs, Robert and Searles, Harold (1980) Intrapsychic and Interpersonal Dimensions of Treatment: A Clinical Dialogue. Aronson.
Little, Margaret (1985) ‘Winnicott Working in Areas where Psychotic Anxieties Predominate’, Free Associations. no. 3: 9-42.
Rosenfeld, Herbert (1971) 'A Clinical Approach to the Psychoanalytic Theory of the Life and Death Instincts: An Investigation into the Aggressive Aspects of Narcissism', Int. J. Psycho-anal. 52: 169-78; reprinted in Spillius (1988), vol. 1, pp. 239-55.
Rutter, Peter (1990) Sex in the Forbidden Zone. Unwin.
Sinason, Michael (1993) ‘Who Is the Mad Voice Inside?’, Psyhchoanal. Psychother. 7: 207-21.
Spillius, Elizabeth B. (1988) Melanie Klein Today, 2 vols. Routledge.
Waddell, Margot and Williams, Gianna (1991) ‘Reflections on Perverse States of Mind’, Free Associations. (no. 22) 2: 203-13.
Young, Robert (1993) ‘Darwin’s Metaphor and the Philosophy of Science’, Science as Culture (no. 16) 3: 375-403.
______ (1994) ‘Analytic Space: Countertransference’, in Mental Space. Process Press, ch. 4
______ (1996) ‘The Cussedness of Psychoanalysis’, in Whatever Happened to Human Nature? Process Press, ch, 6. http://human-nature.com/human/chap6.html
______ (1998) ‘The Analytic Frame, Abstinence and Acting Out’, Distance Learning Unit, Psychonalytic Studies MA, University of Sheffield, http://human-nature.com/rmyoung/papers/pap110h.html
______ (2000) ‘Science and the Humanities in the Understanding of Human Nature’, Inaugural Lecture, University of Sheffield http://human-nature.com/rmyoung/papers/pap131.html
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