Week 2 Assignment 2

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A Call for More Talk and Less Abuse in the Consulting Room: One Psychoanalyst–Sex Therapist’s Perspective

Elizabeth R. Goren, PhD New York University

Guilt, titillation, and anxious confusion about sexuality and sexual relations between therapist and patient pervade the psychoanalytic community. Review of state laws and regulations as well as professional ethics codes reveals a lack of certainty about what constitutes professional misconduct, especially posttermination. Comparing the training approaches of sex therapy and psychoanalysis, the author suggests that psychoanalysis will benefit from shifting its focus on extreme cases of egregious sexual boundary violations onto greater in-depth exploration of clinically universal experience of powerful erotic and negative transference and countertransference. Innovative and experiential educational formats that promote openness, acceptance, confidence, and skill with these dynamics are the best prevention.

Keywords: psychoanalysis, sex therapy, boundary violations, ethics training

I was a sex therapist for many years before becoming an analyst. My training in sex therapy took place in the 1970s, the era of sexual liberation and the initial rise of the behavior therapy move- ment, before the terms sexual boundary violations (SBV) and risk management had entered professional discourse. One of my first sex therapy courses involved a series of role-playing exercises, including one of taking turns giving and receiving massage, a standard sex therapy homework assignment. This is a teaching tool that could never be a part of a professional curriculum in today’s climate of increased sensitivity to sexual abuse and risk manage- ment approach to training and education. We were clothed, and touch was restricted to the kind of back, neck, arms, and hands massage now offered in airports and nail salons. Role-playing patient and therapist, we talked about our bodies and sexuality in a very personal and detailed way with one another.

I offer this vignette in the spirit of bringing the perspective of other treatment models, specifically sex therapy, to our psychoan- alytic approach to the problem of SBV. As I look back, I recall my sex therapy mentors repeatedly and sharply reminding us how crucial it was to maintain the therapeutic frame and professional boundaries. The reputation and very legitimacy of this new form of psychotherapy were at stake. To this day, sex therapists are mind- ful of not being confused with sex surrogates!

Despite the marked differences in thinking and approach, psy- choanalysis and sex therapy are the treatment modalities most dedicated to intense clinical work with sex and sexuality. How- ever, in contrast to psychoanalysis, sex therapy has historically taken a strong unambiguous stand against therapists ever becom- ing sexually or romantically involved with patients. Equally im- portant, sex therapy is more dedicated than psychoanalysis to training that focuses on developing “sex-positive” communication,

that is, talking about sex in a thoughtful, self-aware, and sensitive way that conveys professionalism, respect for the patient, and absolute clarity about the frame and boundaries that I believe reduces the therapist’s as well as patient’s anxiety and resultant vulnerability to acting out.

Psychoanalysis has begun to focus on the problem of SBV, with identification of personal risk factors and theoretical issues. I will focus on aspects of clinical practice, specifically the technical reliance on the patient–therapist relationship, and the culture of psychoanalysis itself—namely, attitudes toward sexuality and sex- ual abuse—that are relevant to SBV and the need for greater consideration in analytic training and education.

Psychoanalysis and Sexual Abuse: A Society and Profession in Turmoil

Although we live in an era of unprecedented sexual liberalism and public intolerance of sexual abuse, actual behavioral reactions to abuse can be wildly inconsistent and hypocritical. Public proc- lamations of moral condemnation stand side by side with “Look the other way” attitudes. We hear of discretionary measures or organized cover-ups of SBV, depending on your outlook, that take place in religious institutions, universities, and professional orga- nizations, including psychoanalysis. At the same time, we hear of policies of zero tolerance taken to punitive extremes, such as a report of an Arizona school punishing a 5-year-old kindergartner for pulling his pants down in the playground with detention and having his permanent record marked with sexual misconduct (Crimestaffer Staff, 2014).

Psychoanalysis reflects these mixed messages and moral con- fusion. Beyond a consensus that physically actualized sexual ac- tivity between analyst and patient in the course of treatment is inappropriate, there is little agreement about what kinds of actions and relations between patient and analyst constitute abuse or exploitation and what should be done about it. For instance, once the person is no longer in treatment, in the view of some analysts as well as laymen, because the person is not in a formal patient– analyst relationship, the relationship falls outside the category of

Correspondence concerning this article should be addressed to Elizabeth R. Goren, PhD, Postdoctoral Program in Psychotherapy and Psychoanal- ysis, New York University, 300 Mercer Street, Suite 23L, New York, NY 10003. E-mail: [email protected]

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mailto:[email protected]

http://dx.doi.org/10.1037/pap0000092

potential SBV. Others strongly disagree. On hearing of a colleague becoming involved with a person he or she is currently seeing or has seen in the past for treatment, the markedly mixed reactions I have heard include the following:

“If they live happily ever after, what harm is there? It happens all the time.” (Read, what’s the big deal?)

“I do not believe it,” followed by either “The patient must be borderline” (read, the one who must be responsible) or “He needs help” (read, it must be mental illness).

“She transgressed?” (Read, a woman? How could that be?)

“He’s a psychopathic predator.” (Read, a man, figures. He’s a criminal. Punish the bastard.)

“How could I have not seen the signs?” (Read, I must be responsible in some way.)

And finally, “How could this be true of my mentor, our institute’s leader?” (Read, what does this mean about psycho- analysis itself, the field I have put my career, my life, my faith in as a philosophy of life?)

The story of psychoanalysis is littered with stories of some of its most renowned leaders becoming sexually involved with their patients. Reactions to tales of Carl Jung with Sabina Spielrein, Erich Fromm with Frieda Fromm Reichman, Sandor Ferenczi with Gisella Palos, and Margaret Mahler with August Aichorn range from fascination to abhorrence but de facto acceptance. And with- out “naming names,” the reader will surely know living leaders whose sexual relations with patients have made for sensational gossip while retaining the analytic tradition of reverence for the personal and intellectual authority of the leader. Our “standard operating practice” of “Do not condone but look the other way” cannot be denied.

The very term SBV conveys our erotic horror (Grand, in press), guilt-laced titillation, and a nearly paralyzing anxiety about the issue that manifests in confusion and inability to locate a moral position that is neither permissive nor excessively punitive, that is, a stand that can be consistently upheld in practice. We speak neutrally of boundaries, but we end up talking moralistically of violators and transgression (implying criminality) or empathically of rehabilitation (implying illness). We proclaim a moral absolut- ism for the basic precept—the therapist–patient relationship is sacred and sexual romantic involvement wrong and harmful— while living a moral relativism that is as much borne of our internalized cultural ambivalence toward sexual abuse and exploi- tation, as it is our analytic recognition of the complexity behind human behavior.

When the possibility of a SBV by an analyst comes to the fore in an analytic community, we react like any other family or community. First, we circle the wagons. The initial shock, hand wringing, and gossip may provoke a call for more talks and workshops on the subject, in the spirit of doing the analytic thing—trying to understand. If the analyst has less visibility and stature, he or the occasional she is quietly shuttled out of the analytic fold, scapegoated, and shunned in fear of contagion and guilt by association, the one that is turned into the negative

model—the exception that proves the rule. If the analyst is a senior, highly respected analyst, particularly if the person has made extraordinary contributions to the field, the community is more likely to be traumatized and in need of collective healing (Honig & Barron, 2013). Periodic flooding pierces institutional patterns of avoidance. A sudden bystander helplessness, a simul- taneous wanting but not wanting to look away, a wanting and not wanting to know what is known, ends in a press on program directors and ethics committees to “do something,” mirroring family and organizational dynamics of abuse. They, in turn, look to their professional ethics codes and seek legal counsel and the guidance of their state regulatory board.

The ironic twist is that existing laws and regulations of profes- sional misconduct, having been greatly based on professional definitions of abuse and exploitation, manifest inconsistencies in ethical standards that are similar to what we see in psychoanalysis. The various professional codes of conduct concur on prohibiting sexual relations with persons currently in therapy. Where they vary is on the matter of posttermination sexual relations and in ways that suggest differences in thinking among the disciplines.

The American Psychoanalytic Association (2009 –2016) leaves no room for equivocation: “Sexual relationships involving any kind of sexual activity between the psychoanalyst and a current or former [emphasis added] patient, by the treating psychoanalyst, are unethical.” It goes so far as to declare that

marriage between a psychoanalyst and a current or former patient, or between a psychoanalyst and the parent or guardian of a patient or former patient is unethical, notwithstanding the absence of a com- plaint from the spouse and the legal rights of the parties.

Similarly, the American Association of Sex Educators Counsel- ors and Therapists (2016), a longstanding organization for prac- ticing sex therapists, takes a clear-cut strict position of prohibiting posttermination romantic/sexual involvement with former clients/ patients and their close family members. The code of conduct also includes certain nonphysicalized verbal interactions in defining abuse and maintains a position that the patient–therapist relation- ship remains unequivocally professional “in perpetuity”:

The member practicing counseling or therapy shall not engage, at- tempt to engage or offer to engage a consumer in sexual behavior whether the consumer consents to such behavior or not. . . . Sexual mis-conduct includes kissing, sexual intercourse and/or the touching by either the member or the consumer of the other’s breasts or genitals. Members do not engage in such sexual misconduct with current consumers. . . . Sexual misconduct is also sexual solicitation, physical advances, or verbal or nonverbal conduct that is sexual in nature. . . . For purposes of determining the existence of sexual misconduct, the counseling or therapeutic relationship is deemed to continue in perpetuity [emphasis added].

The National Association of Social Workers (NASW, 2016), the professional organization for licensed social workers whose prac- tice includes but is not limited to psychotherapy and which applies to certain members of Division 39, holds to the following princi- ple: “Social workers should not engage in sexual activities or sexual contact with former clients because of the potential for harm to the client.” Furthermore, it goes on to declare,

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216 GOREN

If social workers engage in conduct contrary to this prohibition or claim that an exception to this prohibition is warranted because of extraordinary circumstances, it is social workers—not their clients— who assume the full burden of demonstrating that the former client has not been exploited, coerced, or manipulated, intentionally or unintentionally [emphasis added].

Finally, we have the American Psychological Association (APA, 2010) ethics code, the code of conduct currently in place for psychologist members of Division 39. Like the NASW code, the APA code includes but is not limited to professionals practicing psychotherapy and reflects multiple theoretical perspectives. This code specifies a 2-year posttermination clause that recognizes the power of transference but leaves much room for personal judg- ment. Principle [b] of 10.08 states,

Psychologists do not engage in sexual intimacies with former clients/ patients even after a two-year interval except in the most unusual circumstances [emphasis added]. Psychologists who engage in such activity after the two years following cessation or termination of therapy and of having no sexual contact with the former client/patient bear the burden of demonstrating that there has been no exploitation, in light of all relevant factors [emphasis added], including (a) the amount of time that has passed since therapy terminated; (b) the nature, duration, and intensity of the therapy; (c) the circumstances of termination; (d) the client’s/patient’s personal history; (e) the client’s/ patient’s current mental status; (f) the likelihood of adverse impact on the client/patient; and (g) any statements or actions made by the therapist during the course of therapy suggesting or inviting the possibility of a post termination sexual or romantic relationship with the client/patient. (See also Standard 3.05, Multiple Relationships.)

In terms of legal and regulatory standards, every state prohibits professional sexual misconduct through its state licensing boards (Pope, 2001). And at least, or only, again depending on your outlook, 23 states have enacted legislation making sexual contact between therapists and patients in the course of therapy a criminal offense (Berkowitz Glasgow, 1992). Landmark legislation in 1984 by Wisconsin remains one of the wider ranging:

Any person who is or holds himself or herself out to be a therapist and who intentionally has sexual contact with a patient or client during any ongoing therapist-patient or therapist-client relationship, regard- less of whether it occurs during any treatment, consultation, interview or examination, is guilty of a Class D felony. (Wis. Stat. Ann. & 940.22(2) (West Supp. 1990), as cited in Berkowitz Glasgow, 1992)

Legal determination of the extent of harm varies by what, where, and when the sexual contact took place, such as whether it occurred inside or outside the consulting room, and usually only applies to conduct occurring while in treatment. In New York, for instance, a therapist, counselor, psychologist, or psychiatrist who has sex with a patient during the course of a treatment session is guilty of statutory rape. By implication, then, sexual relations outside the consulting room are considered less harmful, subject to a lesser penalty, and potentially not harmful once the person “terminates” treatment, reflecting the mixed messages of the pro- fessions themselves on this issue. The most common legal path followed in this country for professional sexual abuse is civil litigation, which applies tort law and, as such, serves as the primary legal avenue for patients seeking potential redress and for therapists protection against false accusation.

Professional misconduct is based first on an assumption of harm and, second, by virtue of the inherent power imbalance, depen- dency, and intimacy of the patient–therapist relationship, on the inability of the patient to give full consent. Arguments against legal or regulatory control of patient–therapist relations are based on the principle that the government should not be allowed to regulate the private activity of consenting adults and on the prin- ciple that adults are not minors and therefore capable of consent.

Psychoanalytic literature has yet to directly, fully address the questions of harm and consent. Dimen (2011) was the ground- breaking analyst to have had the courage to write about her direct personal experience with SBV. She talked about an incident of physical violation, the “kiss,” and the effect on her and her treat- ment. In the end, she believed that she had been both helped yet harmed by the analyst and briefly touched on the question of consent. Although not a direct victim of a SBV, Burka (2008) wrote about the harm done to her by her analyst in the course of his SBV with another patient. She described the trauma she experi- enced on learning that her analyst had shared information about her and her treatment with this other patient. Other relevant liter- ature on the questions of harm and consent has focused on the analyst’s use of clinical material (e.g., Aron, 2000; Gabbard, 2000; Kantrowitz, 2004).

Given that we can never be fully aware of our unconscious, under what conditions can and should we consider a patient capable of giving informed consent, particularly with regard to issues in relation to the analyst? Furthermore, if a patient is never totally “free” of transference, at what point can we consider a patient as in or sufficiently out of treatment, and free enough of transference and unconscious motivation to be capable of exercis- ing fully informed consent? Reader, I ask, what say you? Respon- sibility for answering these thorny questions gets passed like a hot potato between the professions and their governing bodies, leaving individual analysts unsure what to think and organizations unsure of how to best handle situations involving SBV.

Broad moral questions emerge when violators hold a position of power and prestige. Should they be allowed to teach, invited to present? Should we still assign their articles, cite them in our work? The argument goes something like this. Does a moral failure invalidate what an analyst has to offer intellectually? Should a person who has committed a sexual boundary violation, perhaps, as is most often true, a single case of transgression with one patient, be punished and the community robbed of his or her intellectual contributions?

We witnessed these questions of distinguishing judgment of behavior from the person when Woody Allen, who was alleged to have sexually abused one of his ex-wife’s children and having married another, was given a lifetime achievement award at the 2014 Golden Globes. As Allen (2014) himself put it, “Do you henceforth cease your admiration of me and my work due to the admittedly pretty damn compelling evidence that I molested at least one young child?” Society and psychoanalysis have yet to find a clear-cut answer to this question.

How Analytic Culture and Practice May Contribute to SBV Risk

How has the culture and practice of psychoanalysis made it more a part of the problem than of the solution? First, we have as

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217SBV IN PSYCHOANALYSIS: A SEX THERAPIST SPEAKS

yet to form a consensus or offer clear guidance regarding the question of harm and ethics of posttermination personal involve- ment—most critically of involvement that is romantic and/or sex- ual. This leaves open the situation of patients ending treatment with the intent, consciously or unconsciously, to pursue a romantic relationship. We saw in their ethics codes that certain profes- sions—namely, the American Psychoanalytic Association and the American Association of Sex Educators Counselors and Thera- pists—take a stronger stand than the APA code does, that once a patient always a patient. Although this leaves room for discretion in judgment, and taking circumstances in consideration, it begs the question for those who look to the profession to take a more definitive stand that can be upheld as a basic ethical principle. Certainly more open discussion and guidance of the ethics of posttermination relations in general are needed and, most crucially, of romantic/sexual relations between analyst and former patient.

Second, the groundbreaking work on SBV begun by Gabbard and his colleagues was first brought to the field’s attention as late as the mid-1990s and turn of the century (Gabbard, 1995; Gabbard & Peltz, 2001). With the exception of the continued dedication of the voices of Gabbard (in press), his colleague Celenza (2007, 2010, in press), and Dimen (2011, in press), few psychoanalytic leaders have been willing to confront the severity of the problem, much less taken a strong stand on the matter. This has a left a mixed message that, although becoming sexually involved with patients may be morally wrong and clinically harmful, it is to be expected as an unfortunate one-off inevitability arising from the unique intimacy of the analytic relationship, maybe even a part of a leader’s mystique. In their study of one institute following a SBV, Honig and Barron (2013, p. 25) reported, “One senior analyst wondered about our complicity and whether our idealiza- tion of X and our narcissistic investment in his significant contri- butions to psychoanalysis had blinded us to possible danger sig- nals.”

In contrast to the relative silence in psychoanalysis, Masters and Johnson (1966, 1970, 1977) through their research and clinical work, became highly vocal advocates of criminalizing therapist– patient sex, considering it rape. According to Pope (2001), these founders of sex therapy were responsible for bringing public attention to professional sexual misconduct. And although sensa- tional movies such as Kinsey and Masters of Sex have portrayed the sexual shenanigans of these leading sexologists, there is a crucial distinction between ethical responsibility in relation to colleagues and responsibility to and for patients.

Furthermore, institutes that foster a cult of personality and general analytic proclivity for leader worship become ripe climates for potential exploitation and abuse. Again, compared to the ana- lytic tradition of reference to Freud and subsequent “forefathers,” sex therapists tend to be far less devotionally bound to their originators and other leaders. Overarching endowment of faith, power, and prestige in the field’s leaders not only potentiates their vulnerability to overinflated self-esteem but can also contribute to personal isolation, a psychological mix that increases an analyst’s risk.

Psychoanalysis has tendencies to idealize not only its leaders but psychoanalysis itself as a therapy practice. It can lead us to be unrealistic about whom we can help and what we accomplish in certain treatment situations. This can lead to countertransferential resistance and feelings of inadequacy about terminating an analy-

sis that has reached the limits of what is possible for that analytic pair at that time. Today analysts work with pathology that is sometimes accompanied by acting out, adding to the analyst’s challenge to maintain boundaries while continuing the treatment. The shift in thinking from the ideal analyst image as the all- knowing father to the all-loving mother also makes it harder for today’s analysts to accept the limits of a treatment without feeling that they have somehow failed. In well-meaning but potentially doomed efforts to keep trying to rescue a faltering treatment, analysts risk falling on that slippery slope because they feel the need for consultation to be a personal weakness. Far more accept- ing of our patients’ limitations than of our own, we struggle to not take the outcome of the work personally. As Chessick (2001) pointed out, professional narcissism is “the great enemy of integ- rity” and can end up being the downfall of the most gifted and well-intentioned analyst.

In contrast, the professional identity of sex therapists is that of helper, not healer, and consequently sex therapists do not hold themselves or their patients to the dream of a “total makeover” of the psyche and living. Perhaps we analysts can have a more open attitude to treatments that may be limited in frequency, length, and goals. Not only will this reduce the paradigm stress on boundary faltering, but I also think it will enhance our appeal and relevance in contemporary society.

Clinical Training on Sex in the Consulting Room

How surprised was I when, as a young sex therapist, I began analytic training and found my teachers and supervisors to be just a tad more uncomfortable with real sex talk than I had expected from those who were carrying forth Freud’s legacy of bringing sexuality and the unconscious into the foreground of Western culture’s understanding of human nature! My training almost singularly focused on the patient’s sexual feelings and impulses, with rare open discussion of the analyst’s sexual feelings and impulses, particularly in relation to the patient. Under the rationale of transforming impulse and action into symbol and meaning making, we were taught to analyze, sometimes in effect analyzing away, sexual material. Although the erotic transference was im- plicitly elevated, in some quarters even considered the hallmark of a complete analysis, it often ended up being unwittingly relegated to a nonreal status. With the conceptual shift from libido/drive model to a more relationally based paradigm, the thinking went from, “It isn’t me you actually desire but your mother, father, etcetera” to “It isn’t sex you really want, but love, recognition, attachment, etcetera.”

One can argue that this is precisely what distinguishes psycho- analysis from other forms of therapy—relating to the patient’s fantasies, longings, and impulses symbolically, not concretely. And we know that a SBV is precisely that very failure of symbol- ization into psychic equivalence, with the analyst treating sexual desire as “real” rather than an entry point for broadening and deepening analytic exploration. Equally problematic is a counter- transferentially driven premature foreclosure of exploration. This can take place in many forms, including the use of theory as an unconscious move on the analyst’s part to defensively defuse the reality of intense and sometimes overwhelming sexual feelings, without adequate internal or interpersonal processing.

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Green (1995) attributed the de-sexualization of psychoanalysis to American puritanism. I think it is also a natural reaction to the increased emotional pressures on the analyst in today’s relationally weighted paradigm— one that relies on the analyst’s use of the self as an instrument, in a networking culture that presses for the analyst to be “real,” more self-disclosing, and intimate in social engagement than in previous eras. The accretion of these factors makes it difficult for the analyst to balance personal and profes- sional relatedness, a way of being that is neither oversexualizing nor defensively de-sexualizing.

So, how can we learn and help others learn better sexual communication when in the throes of intense transference coun- tertransference? Even more challenging, how do we become more skilled in recognizing and handling countertransference that is being dissociated into detachment, hostility, or shaming that ef- fectively silences exploration or gets enacted in seductive speech and manner? For, as Davies (2013) succinctly put it, “Talking sex can be as exciting or even more exciting than doing sex” and, I would add, as potentially harmful when not managed.

A small body of literature is just emerging on handling erotic countertransference (Davies, 1994, 2013; Gentile, 2013; Jørstad, 2002; Renn, 2013; Slavin, 2013). Talking of the potential thera- peutics of playful flirtation, such as what Gentile (2013) and Renn (2013) speak of, without more specific guidance and greater open- ness regarding countertransference in general can leave a consci- entious analyst uncertain about how to responsibly proceed with patients. The challenge for us as analysts, supervisors, and teachers is to acknowledge the struggle and to help each other navigate the tricky path of respectful yet really open communication about sex and sexuality.

We are not only uncomfortable and inadequately trained to deal with erotic countertransference, but we are also equally uncom- fortable and minimally trained in the art of dealing with the intense feelings of shame, humiliation, frustration, aggression and hostil- ity, insatiability, fear, and longing that can accompany or precip- itate a reactive erotic transference and/or countertransference. Left unexplored, countertransference states that feel threatening, such as hostility and disgust, or even more acceptable states, such as boredom and hopelessness, risk being unconsciously transformed into more ego-syntonic states of love and Eros. We need to target theory of technique and clinical training on specific ways to help an analyst preserve a safe environment for both patient and ther- apist. This requires the analyst finding an experiential position that allows for “evenly hovering attention” and sovereignty in the midst of intense erotic, romantic, fearful, and hostile and other highly charged narcissistically inflected feelings.

In our preoccupation with that fateful boundary crossing into the physical realm, it is easy to miss early warning signs of SBV or to recognize emotional abuse that is never physically actu- alized but, as a form of gas lighting, can have a seriously damaging, even traumatic, impact on the patient. As therapists, supervisors, and teachers, we need to be more attentive to those critical points where ego-dystonic negative and positive coun- tertransference intersect, the “middle slope” (Arlene Steinberg, 2015, personal communication) when the therapist momentarily loses grounding, reality testing, and a sense of control as the guardian of the analysis.

Recommendations and Conclusions

As a psychoanalyst and sex therapist, as someone who has served on professional ethics committees for decades, I call upon my brothers and sisters in the analytic community to think more about what we really believe constitutes sexual exploitation and abuse in therapy. In this vein, I think that Division 39 might consider developing its own set of standards and guidelines or its own distinct ethics code— one that takes into consideration the complexities of boundary crossings, assesses the enduring power of transference and countertransference, and, most crucially, ad- dresses the general issue of posttermination relationships and takes a more definitive position on sexual and romantic involvement.

I think we can be more creative in our approach to training and continuing education on the multiple sticky dynamics that come into play in analytic practice today. As it now stands, psychoanal- ysis relies first and foremost on the training analysis and supervi- sion to develop the quality of self-awareness and self-questioning needed for responsible functioning in the consulting room. Courses and workshops on ethics and boundary violations, even when required, tend to be proforma and too often end up feeling so morally freighted as to compromise their appeal and utilization. First we need to put more focus in courses, workshops, and supervision on intense and challenging transference and counter- transference dynamics without the looming specter of SBV, with its association to danger and professional failure. This kind of em- phasis will hopefully be far more welcoming to analysts at all stages of career.

To develop more comfort and skill in addressing sexuality in the consulting room, the atmosphere of any forum needs to be one that explicitly attempts to foster freer disclosure of one’s less than ideal reactions to patients. Toward this end, I suggest we need to focus less on didactic and more on experiential dimensions of understanding and learning. Educational formats that privilege theory over technique, which we tend to rely on today, can miss the mark of what we need more of in our field, particularly with issues of intense erotic and related material— honest, open self-confrontation and disclosure of personal experience and vulnerability. For instance, when structur- ing conference panels and classes, instead of relying on the stan- dard format of speaker or instructor delivering a paper or lecture from the distance of a lectern, we might foster programming formats that are more experiential and group discussion oriented.

Finally, I suggest we pay more attention to factors inherent to psychoanalytic culture and practice that contribute to SBV. The bond and depth of intimacy between patient and analyst, over the course of time, put enormous pressure on the therapist and patient to become more personally involved. We hold ourselves to much higher goals—personal transformation and fulfillment—than more limited, structured types of therapy. But high ideals combined with individual risk factors and abstinence requirements can become combustible in an intractable impasse or when the limits of what can be done in a particular analysis are reached. This also includes reaching that inevitable moment in the best analyses, what Celenza (2010); refers to as the predestined analytic question, “Why cannot we be lovers?” Over the decades, one analyst after another has warned of a certain hubris in the field (Chessick, 2001; Hoffman, 1998; Slochower, 2003; Weinshel & Renik, 1991) that can blur the line between ideals and idealization, between our willingness to “never say die” and our unwillingness to let go.

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219SBV IN PSYCHOANALYSIS: A SEX THERAPIST SPEAKS

Psychoanalysis is all about human potential and limits. But who does not love that masked hero Super[wo]man! Perhaps we can we take a few lessons from what we tell our patients as well as what other treatment modalities have to say on some things. Certainly our identity can handle it. Our reputation and self-respect depend on it.

References

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