Psychoanalysis and Psychotherapy

Free Associations

HOW ARE WE TO WORK WITH CONFLICT OF MORAL STANDPOINTS IN THE THERAPEUTIC RELATIONSHIP? by Robert M. Young

I want to begin by saying that the terms of reference of this series of lectures grated on me, in particular, the word ‘power’. One thing it conjured up was the criticism made by people who say we use our power over our patients to brainwash them, that the psychotherapeutic relationship is inescapably authoritarian, domineering, coercive. This was widely said in the sixties by leftist and feminists and others who sought a therapeutic relationship that was more equal, co-counselling, for example, where the client and the therapist took turns exposing their problems. In my experience, most people who took up that position eventually saw the merits of relatively orthodox psychotherapy, and many have trained in conventional psychodynamic psychotherapy. I asked my partner, who is also a psychoanalytic psychotherapist, what the term power conjured up for her and got an uncharacteristically sharp response. She said, ‘I hate that word. It’s used by humanistic therapists who are afraid of authority, difference and knowledge and want us all to be the same. It’s like saying colour doesn’t matter. They confuse the abuse of power with the use of power. They assume that all exercise of power is abusive.’

Well that’s a lot to chew on, isn’t it? I am sure that some of you will have things to say in the discussion about those thoughts. The terms I prefer are ‘authority’ (in the sense of authoritative), ‘competence’, ‘trust’. I believe that it is inescapable that the patient or client has eventually to place him- or herself in the hands of the therapist, that dependency is, for the course of the treatment, essential, even if it takes the form of an underlying commitment to the process, while he or she kicks and screams on the surface, accusing the therapist of all sorts of abuse and I don’t know what all. It involves a regression. After all, children of caring parents gain strength from dependency which provides a secure base for growth, maturation and increasing independence.

Still feeling uncomfortable, I looked at a dictionary for definitions of power and found some that I found more congenial – ‘ability, skill and capacity to do something’; ‘control or influence over other people’; ‘ability to influence people’s judgment or emotions’. Notice that control and influence are prominent words. For a number of reasons, I don’t feel uncomfortable about that. I don’t think we can be value-neutral in psychotherapy, which is not to say that we should indulge our prejudices or be evangelical or even, for the most part, up front about our beliefs and politics. I just believe that ‘therapeutic neutrality’ is a bit of a will-o-the-wisp, that our patients discern more or less accurately what we feel and believe about this and that. It’s all grist for the mill, and one hoped-for outcome is the ability to tolerate and respect difference on both sides.

These things can be relatively benign or seriously worrying. I had a patient who read The Daily Mail. I cured her. She is now a Guardian reader. You may be shocked, but she had been active on the left in her native country and had opted for The Daily Mail because of its simplified vocabulary. Moving on The Guardian meant treating her English-language self with more respect, and, of course, its politics were nearer to her own than those of The Daily Mail. I have one at the moment who stubbornly continues to read The Times, and I have been tolerant about that.

Turning to more distressing matters, I had a patient who told me, after a year of working together, that he could not ejaculate unless he spanked his partner. Indeed, it was important to him that he could see the mark, the imprint, of his hand on her bottom the next time they met. This, he earnestly assured me was ‘just a bit of fun’ and that his partners went along with it willingly. He was also shy about penetrative sex. In fact, he had a phimosis, a condition which made retracting his foreskin very painful. He waited until his mid-thirties to have this corrected by circumcision. Where he was really at home was with prostitutes who would endure spanking for pay. He also spent a lot of time viewing and masturbating to porn sites on the internet specialising in pictures of spanking, of which, he assured me, there were many, ‘so what’s abnormal about it?’ Unsurprisingly, after he recovered from the operation he was still reluctant to have penetrative sex. In fairly short order he lost his girlfriend over this and mourned the relationship over many months. He eventually began a new one and did have intercourse, but he could not ejaculate and said, quite poignantly, that I had taken away his main pleasure and had left him with something merely frustrating. He said many times that he hoped that I would not leave him in mid-stream, ‘no longer a spanker but not yet a fucker’.

Throughout this sad tale we were, of course, looking at the dynamics of his family of origin. His father was judged a failure, having stayed in the same clerical job all his working life, though he was admired by many for his cultural activities, which were not remunerative. Unlike most of their neighbours, the family remained unable to buy a car or other symbols of affluence. My patient’s mother wore the pants in the family and was disdainful of her husband, an attitude she instilled in the children, an obese sister who never married and a brother who seemed to be okay. They were also members of a persecuted minority community, and my patient had once had his hair cut off as punishment for something he had not done.

You will have spotted the grounds for low self-esteem through identifying with his father, for fear of castration by the mother and the local persecutors and the vengeance toward womankind underlying the ‘bit of fun’ of his spanking. We made slow progress, and I eventually sent him and his partner to couple therapy in parallel with his ongoing work with me. This combination eventually worked, they married, and I recently received a card announcing the birth of their first child.

He’d once said to me that he was sure of one thing – that I’d never be willing to have a child. Without hesitation I said I have five (another arrived while I was seeing him). You may be surprised buy this bit of self-revelation. I was, too, but, on reflection, I decided that I felt compelled to say I was not going to collude with his proffered comradeship in evading traditional male sex roles and practices. I was saying, ‘Enough!’

Which brings me to the issues illustrated by this tale. Throughout my work with him I was in no doubt that spanking –- especially with the enduring palm marks –- was wrong. More generally, I am sure that inflicting pain in the course of lovemaking is wrong, both psychologically and morally. I also firmly believe that penetrative sex to orgasm is good, though, I hasten to add, it is not the only good in lovemaking. At least as important as my beliefs about these things is the conviction that he thought so, too, which was why he came into therapy and stayed and took part in the expensive combination of working with me and in the couple therapy extending over many years, five, as I recall. So, you could say that the moral conflict between us was only on the surface. He could at any time have broken off the therapy and carried on with his perverse practices and would probably have ended up a lonely old man, a fear he expressed often.

Two other patients come to mind, one of them also determined not to have children, yet hoping not to lose his wife, who did, and who was threatening to leave him if he continued to procrastinate. He had fantasies of pulling birds, which he had done promiscuously before meeting her and of one day driving his powerful motorcycle into a wall and ending it all. I think I helped him understand why his largely absent hippy mother left his baby self un-cared-for and left him bitter and avoidant. I recently received an email message about the arrival of a child of his marriage.

My other example is a vicar who had never enjoyed intercourse and had only once come close to marriage. His preferred form of sexual expression was to indulge in mutual masturbation with young boys or men who were not fully adult, i.e., were of age but socially maladroit. He did this while drunk, which somehow allowed him to pretend it was not happening or that he was not fully responsible. His father had died when he was one, he and his mother moved in with a domineering grandmother, and he was persuaded to remain in that household when his mother remarried when he was ten. He, too, was avoiding threatening womankind and the emasculation he saw had befallen his grandfather. While he was working with me this patient tried making love to several women, but it was no good. His partner in masturbation got married, and he was left to find a way of life that was not unacceptable to a man of the cloth. He finally chose celibacy. He, like the other two patients I have mentioned, came to me with a sexual practice he knew to be in stark conflict with his own morality. I wish he had made it all the way to heterosexual love and intercourse, but his final sexual resting place was at least morally acceptable to him, the more so because of his advancing age.

You may say that these examples are not really moral dilemmas or conflicts, since each of my patients knew that he ought to and wanted to change. I submit that practically all patients do know such things. On the other hand, I have and have had patients whose sexual practices are not mine but who came into therapy for other reasons. I have taken the line that ‘If it’s not broke, don’t fix it’. But if someone came who was inflicting or receiving severe pain I would work to change that, as I would want to change the beliefs of a member of the National Front, for example, a problem with which I am glad to say I have not been faced. I have not worked with murderers or paedophiles, either, but I have discussed working with murderers with Arthur Hyatt Williams, who spent many years doing so (Hyatt Williams, 1998). He reports that, without exception, those who are not psychotic are full of remorse. Psychotherapists who work with perverse children also report that the inverted moral order of such patients rarely controls all of the personality and that moral discourse is eminently possible. The earlier you get them the better the prognosis (Waddell and Williams, 1991). The psychoanalyst Michael Sinason (1993) claims that all of us have a Jekyl and Hyde personality and that the therapist should sit it out when the Hyde one is in the ascendant and wait to work with the Jekyl one when it reappears. I am not saying that there are no real moral conflicts between therapists and patients –- over infidelity or immoral business practices, for example –- but I am saying that the patient is almost invariably in close touch with what conventional morality would dictate and is probably being persecuted by a punitive superego. Our problem is to get in touch with a less split-off part of the mind, a reparative conscience that is in sympathetic contact with a good internal object and can contemplate reparation as an advance on torment or defiance.

I should also grant that there are varying degrees of moral awareness and accessibility in the people with whom we work and that some people are at the end of the continuum, with their minds wholly or nearly wholly in the grip of an inverted moral order where ‘fair is foul and foul is fair’, this being a definition of the perverse (Waddell & Williams, 1991). I have in mind recidivist paedophiles, many of whom begin abusing other children when they are still children themselves. I have a colleague who works with such people, and he stresses, as I said a moment ago, how important it is to begin working with them at as early age as can be managed. One of the leading figures in this field, Mervin Glasser, pointed out that sexual perversion, e.g., fetishism and paedophilia, is the only form of psychopathology where the symptom results in orgasm, i.e., is directly hedonically thrilling. It is not a simple matter to place the gratifications of moral restraint up against such an immediately pleasurable denoument, as the newspapers regularly make all too clear.

I also want to mention another form of perverse thinking, one where the mind is in the thrall of a destructive narcissism. Here the power lies, not with the patient or with the therapist but with an internal pathological organization. In a gripping essay on how minds under the control of the death instinct function to keep the therapist at bay, Herbert Rosenfeld refers to a ‘gang in the mind’. He writes,

The destructive narcissism of these patients appears often highly organised, as if one were dealing with a powerful gang dominated by a leader, who controls all the members of the gang to see that they support one another in making the criminal destructive work more effective and powerful. However, the narcissistic organization not only increases the strength of the destructive narcissism, but it has a defensive purpose to keep itself in power and so maintain the status quo. The main aim seems to prevent the weakening of the organization and to control the members of the gang so that they will not desert the destructive organization and join the positive parts of the self or betray the secrets of the gang to the police, the protecting superego, standing for the helpful analyst, who might be able to save the patient. Frequently when a patient of this kind makes progress in the analysis and wants to change he dreams of being attacked by members of the Mafia or adolescent delinquents and a negative therapeutic reaction sets in. This narcissistic organization is in my experience not primarily directed against guilt and anxiety, but seems to have the purpose of maintaining the idealization and superior power of the destructive narcissism. To change, to receive help, implies weakness and is experienced as wrong or as failure by the destructive narcissistic organization which provides the patient with his sense of superiority. In cases of this kind there is a most determined chronic resistance to analysis and only the very detailed exposure of the system enables analysis to make some progress (Rosenfeld, 1971, reprinted in Spillius, 1988, vol. 1, p. 249).

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,

If the patient’s advances were returned it would be a great triumph for her, but a complete defeat for the treatment. She would have succeeded in what all patients strive for in analysis — she would have succeeded in acting out, in repeating in real life, what she ought only to have remembered, to have reproduced as psychical material and to have kept within the sphere of psychical events. In the further course of the love-relationship she would bring out all the inhibitions and pathological reactions of her erotic life, without there being any possibility of correcting them; and the distressing episode would end in remorse and a great strengthening of her propensity to repression. The love-relationship in fact destroys the patient’s susceptibility to influence from analytic treatment. A combination of the two would be an impossibility.

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).

The forbidden zone is a condition of relationship in which sexual behavior is prohibited because a man holds in trust the intimate, wounded, vulnerable or underdeveloped parts of a woman. The trust derived from the professional role of the man as doctor, therapist, lawyer, clergy, teacher or mentor, and it creates an expectation that whatever parts of herself the woman entrusts to him (her property, body, mind or spirit) must be used solely to advance her interests and will not be used to his advantage, sexual or otherwise.

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.

REFERENCES

(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