Monthly Archives: November 2013

What about sex in therapy?

“A patient enters therapy and says that her presenting problem is having sexual desires for her previous therapist. How do I understand that and what do I do?” Thanks to one of our readers for presenting this important question.

Psychotherapy is talk therapy. We talk to one another to form a healing relationship so that the patient can become at one with the emotional truth of her life moment by moment. This prospect, however, can be terrifying, as we all know. To avoid the anxiety of emotional intimacy, the patient may use sexual intimacy as a defense. Sexual intimacy in therapy is always a defense. And it can ward off anything.

Frequently, patients can use sexual feelings to ward off their rage. “Oh no. I’m not angry with you; I want to make love to you.” This is the classic defense of reaction formation: acting the opposite of what you feel. The patient who experiences what you can offer and envies your abilities may try to have sex with you in order to reduce you to a sexual object, devalue you, and no longer feel envy. “You just wanted to have sex with me. That shows you are no better than anyone else and there is nothing else you have to offer me.” A patient may express a desire to have sex with you as a test to see if you will break boundaries like her previous therapist did. A patient may desire sex to avoid feelings of loss. “If I have sex with my therapist and bond with him, I don’t have to face the grief over the terrible death and loss of my husband.” A patient may have competitive urges with women (what we call oedipal conflicts) where she wants to have sex with the therapist and, thus, defeat the therapist’s wife and become number one rather than feel like the number two woman in his life. A patient may also have anti-social traits where she likes to destroy people. In such a case, she may lure a therapist into having sex and then take pleasure in threatening him with blackmail. A patient who has been sexually abused may be enacting a past trauma as a test of you to find out whether you can help her with her feelings rather than exploit her.

As I said, sex can be enlisted to ward off any feeling and can be an enactment of many different types of conflict. But let’s also take a look at the therapist’s part in these enactments. Research shows that male therapists who enact this defense often do so at times in their lives when they are depressed or have suffered recent losses. Searles talks about how the therapist, despondent about curing a severely ill patient, may act out an unconscious belief that the sexual act and therapist’s physical love will heal the patient. And then, of course, there are some therapists with anti-social traits who simply exploit patients.

With this background understanding that sex in therapy is a defense, then we can answer the question of what to do. When a patient presents with the problem of having had sexual feelings with her previous therapist, find out more about her previous therapy. By exploring specific interactions and examples, you will discern the triangle of conflict. In other words, what feelings were being warded off by the sexual feelings? Then we could help the patient face those feelings. At the same time, since those same feelings will arise in the new therapy, the therapist must pay close attention to the patient’s feelings toward her. If and when the patient experiences sexual feelings, notice what feelings the patient was experiencing just before. That will allow you to see the process: feelings, then the defense of seeking sexual intimacy. Then you can point this sequence out to the patient. If we can help her tolerate her feelings without covering them up with sexual urges, we can help her let go of sexual impulsivity. Then, when she decides to be sexually intimate with a lover, she won’t be the hostage of her defense of impulsivity. She will be the one making the decision and having no regrets the next day.

Now some of you might counter: isn’t it possible that feeling sexual feelings in therapy might be progress for some patients? That is certainly true. A patient who was schizoid and withdrawn or a patient who was sexually abused as a child and who finally experiences sexual desires again would be experiencing progress. Yet it is essential to remember that the progress would be in experiencing her own sexual feelings, not in acting them out in therapy.

If sexual feelings are acted out in therapy, you become suddenly useless as a therapist. The analyst Sandor Ferenczi wrote a beautiful paper on this problem. He spoke about a “confusion of tongues.” The abusive parent may confuse the child’s wish for comfort and love with the adult’s wish for sex. When the patient expresses her feelings or desires for sex, ask yourself: what defensive function is this serving right now? What feeling is the patient warding off? What kind of destructive relationship is the patient creating? This proposed destructive relationship is a test: are you willing to explore, understand, and help her bear her warded off feelings, or are you willing to collude with her defense, act it out, and become useless as a therapist? When she talks about sex with you, she is inviting you to exploit her and abandon her. Your task is to help her see how she invites you to become a corrupt object who uses her.

And finally, if you fall into the trap of thinking that your “love” will cure the patient through sex, remember this: the patient’s problem is not due to a lack of your love. The problem is that the patient does not love herself. No matter how many people she has sex with, all that sex will not compensate for her self-hatred and self-neglect. She seeks love in all the wrong places: other people. If you love her and she does not love herself, no healing can take place. Instead, help her see the cruel ways she neglects and hurts herself. Once her self-hatred turns into self-compassion she will experience the inner marriage between herself and her inner life. With that inner marriage in place, it will finally be safe for her to date again and find a love in the outer world that matches the love in her inner world.

How much anger is enough?

“In ISTDP there is a lot of focus on recognizing, labeling, and viscerally experiencing one’s feelings. But how do we get clients to deal with anger in their everyday life? Is it enough “just” to recognize, label, experience, and thus contain the feeling, or should you respond more outwardly so that others get to know your limits? How do we prepare clients to handle their anger in their everyday lives?” Thanks to Erik for this important question.

Why do we focus on feelings in the first place? We focus on feelings because the patient’s attempts to avoid his feelings (his defenses) create his presenting problems. Once he can face his warded off feelings, he does not need to use defenses, and then he won’t have his presenting problems any more.

But this raises more questions, which Erik poses for us, and correctly so! In the therapy room, we encourage the patient to experience his feelings as deeply as possible so that he can access the previously repressed unconscious feelings which have been triggering his unconscious anxiety and defenses. Once he can bear those unconscious feelings, unconscious anxiety drops, and the defenses against those feelings are no longer necessary. However, there is the additional question: what is the relationship between accessing these deep conscious feelings in therapy and the conscious adaptive channeling of feelings in everyday life?

In everyday life our task is to feel our feelings so we can receive the information they can offer. Perhaps the anger arises because of the need to set a limit. Then the patient can enlist her anger in the service of setting a limit with an abusive boyfriend. She might set that limit by not returning his calls, changing her phone number, telling him that his behavior is unacceptable and that that behavior must leave the relationship or she will. Or she might enlist that anger in the service of filing a restraining order. In other words, depending on the situation, there is a spectrum of responses that would set an appropriate limit. And anger is the emotion that would help her do so.

First we help her face her rage in session so she can experience it without anxiety and defenses. Sometimes that is enough for the patient to use her pre-existing skills to assert herself in an adaptive way. Sometimes patients may not have those skills. In those cases, we might help the patient think about how to assert herself.

Sometimes therapists give patients advice or patients take assertiveness training classes. But then the patients don’t use the advice or training. Why? Because their anxiety and defenses block them from using this knowledge.

So task number one: help the patient face her rage as deeply as possible while restructuring her anxiety and defenses. Then she can put her knowledge into action. If she does not really know what to say or do, then you can offer advice and she’ll be able to put it into action because you have restructured her anxiety and defenses.

Take home point: build the patient’s capacity to face her rage without anxiety and defenses. Then she can use her knowledge to assert herself. If she lacks the knowledge (What John Gedo calls an “apraxia”), your advice and suggestions may give the patient guidance on how to channel her anger into adaptive action in a way that fits her. Since she can now tolerate her feelings, she will be able to integrate your advice and set the limits she needs to set.