Tuesday, February 05, 2008

You Don't Have To Say It All


Last night's episode of In Treatment got us thinking about how uncomfortable it is when the patient falls in love with the therapist. LadyAK47 wrote in to say that it's very awkward when clients tell her she's attractive. She says, with an tone that I think conveys a hint of guilt, that sometimes she just ignores them and she hopes she'll learn to deal with it better.

Anonymous wrote in and said:


I just ended eight years with my therapist. I started leaving about two years ago. Five years ago, I told her I was sexually attracted to her. No discussion about it except an "Oh that's natural, it will pass once we work through your transference issues." It was never discussed again. I got a very brief description of transference with the explanation of me being bright and I would understand it. I thought I did except I wanted to f**k my therapist not my mother. I never shared anything significant with her again and did my therapy by writing but I was still silent as I shared it with no one. I thought this episode was so painful to watch but totally unrealistic, or maybe she is just narcissistic. I would never say to my therapist, "I want you to f**k me" because I would worry how uncomfortable that would have made her and myself. I am betting this is true of most people who find themselves in that situation. Of course therapy is supposed to be the place where it is safe to say anything but I really think that after a time with your therapist, you do start monitoring what is said and their comfort level other than your own (the client). -- ** mine.


So we've all heard that therapy is supposed to be uncensored free association, no holds barred. If it pops into your mind, it should be said, and perhaps the psychoanalysts want it that way. But let's be real here: shrinks/therapists are people, and while therapy should be a safe place to share intimate, uncomfortable, and embarrassing thoughts and feelings, and behaviors, there are limits. And as with any relationship, there are consequences. Many people have very successful psychotherapies without sharing their every thought. And if the patient's feelings are expressed in a way that makes the shrink feel threatened, uncomfortable, totally miserable, completely and irrevocably insulted, or sexually vulnerable, then one consequence may be that therapy becomes un-workable.

LadyAk47, sometimes the best, easiest, and least hurtful thing to do is to ignore an uncomfortable comment.

And to anyone who wants have sex with their therapist, maybe it's just fine if it isn't expressed in crass and threatening terms, but caged in gentler and subtler ways.

In real life, if a patient comes on to a therapist as strongly as Laura did to Paul the sequence of events is clear: Paul should document Laura's advances, he should avoid doing anything that she might misread as leading her on, he should seek formal consultation, and he should end the therapy. A psychotherapist can't be alone in a therapy session with a patient who is asking for sex. The risks of real or imagined abuse get too high and the repeated requests for sex get in the way of any real therapeutic work getting done-- instead it becomes a paradigm for frustration, discomfort, and sometimes for inappropriate sexual activity.

Onward to Episode 7

17 comments:

Sarebear said...

I feel like a @#$@#$ fool for asking that one question then (and no to anyone who didn't read it, it wasn't about anything wierd.)

But then, that's not a novel experience for me.

Dagnabbit, and here I was hoping I could write a novel . . . . Dinah? You have novel experience . . hee hee.

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NeoNurseChic said...

But don't you still believe that therapy should be a safe place to explore something as big as falling in love with the therapist, such as what anonymous is saying? Afterall, it is a really big deal, and I can't imagine the therapist just ignoring that, if it was brought up in a serious way and more than just, "Oh I find you attractive" but rather, "I really think I'm in love with you" or "I am having a problem with the fact that I'm physically attracted to you" or whatever a patient might say. Even if it makes the therapist uncomfortable, this is still a big part of the therapeutic relationship, and deserves attention. I feel really badly for anonymous that his (her?) therapist just blew off his feelings instead of exploring it more. It just shows, to me, that the therapist cannot handle the patient's feelings.

One of the biggest things my psychiatrist says to me when I don't want to talk about something is, "Do you not think I can handle what it is you have to say?" Or he'll ask if I don't think he can handle my anger or my feelings, etc...whatever the situation is that I'm either talking about or avoiding talking about. The fact that he can handle it is what makes me be more honest and open with him - I know that he wants to hear what I have to say, and that he can handle it.

I understand that there are limits in that if I started threatening him or making him extremely uncomfortable somehow, maybe he would react differently, and I'm not the type of person that would say something rude or something that even might make him really uncomfortable intentionally anyway. However, he always reminds me that every thought I have is important to him - and this is usually because I've avoided saying something for some time that he is drawing attention to.

Anyway, I guess what I'm saying is that the ability to share my thoughts and feelings with my psychiatrist and the knowledge that he can handle what I have to say makes a big difference. It allows me to avoid worrying about hurting him or upsetting him with my words. While I never truly stop thinking about what he might be thinking about what I'm saying or what impact my words might have on him, at least he has let me know that he can handle anything I have to say, and that leaves the room open for discussion about anything on my mind. I just find this really helpful.

Take care,
Carrie :)

Alison Cummins said...

Dinah, following your long quote of Anonymous' comment you said:

"Many people have very successful psychotherapies without sharing their every thought. And if the patient's feelings are expressed in a way that makes the shrink feel threatened, uncomfortable, totally miserable, completely and irrevocably insulted, or sexually vulnerable, then one consequence may be that therapy becomes un-workable."

and:

"And to anyone who wants have sex with their therapist, maybe it's just fine if it isn't expressed in crass and threatening terms, but caged in gentler and subtler ways."

You seem to believe that Anonymous was sexually threatening, that you are saying that the problem with Anonymous' therapy was that Anonymous was crudely leering at the therapist like a drunk at a topless bar and of course the therapist avoided the subject.

I didn't get that at all from the comment.

For one thing, if the therapist felt so threatened, it would have made sense for her to terminate the therapy five years ago. That she didn't suggests either that the introduction of the topic of the therapeutic relationship was handled in a non-threatening manner, or that she responded to aggressive behaviour in an inappropriate way.

Not that you're necessarily wrong about the commenter's behaviour - boorishness is certainly a valid interpretation. Sex and attraction are areas where many people's feelings become so strong that they become very self-absorbed, self-centred, and lose all sight of other people's wants/ feelings/ interests. It happens all the time.

It's also possible that the therapist could have dealt with the situation better, or that the patient's honesty about lust interfering with the therapeutic relationship was actually offered quite timidly, or both.

For instance, it's entirely possible that the therapist felt free to dismiss the subject because her client didn't make a big fuss about it, and she allowed herself to ignore a significant problem precisely because it was presented so politely, without insistence.

Really, it happens all the time.

Alison Cummins said...

Personal bias: "transference" seems a way of "explaining away." It doesn't lead to anything. I would say rather that the therapist was a kind, non-threatening woman who was very interested in her client and listened well. That this was pleasing to the client. I can say it's natural to have warm feelings toward the therapist under these circumstances without invoking Freud.

Customers in strip clubs do this all the time - they often are convinced that the strippers really like them; and maybe they do. It's impossible to tell. Acting like they are attracted to the customers is the strippers' job, and many of them do it very well. It's normal for customers to be confused, and we don't have to invoke transference to understand that. Why does it have to be transference when the paid professional has an MD?

Not that Dinah invoked transference, but I would be skeptical of someone who waved a big word at this sort of thing and told the client that only a stupid person wouldn't figure it out on their own. That's mind games. Why not just say flat out, "Of course you think I'm nice, I'm paid to be nice to you. That's what the therapeutic relationship is. Can you deal with the ambiguity?"

The client is not always wrong. (We often are - people generally are often wrong about lots of things in lots of circumstances. Therapy clients too.) But not always, and it's not fair to assume that everything that goes wrong in a therapeutic relationship must be the client's fault.

Rach said...

Carrie, I think what your psychiatrist has done is take the elephant out of the room, so to speak.

dinah said...

Alison:

Actually, I wasn't referring at all to the comment by Anonymous, I was referring to the character Laura who repeatedly, flirtatiously, without any regard for his marriage, tells Paul she is In Love with him and says "I want you to F**K me."
This degree of insistence, intrusion, and wish for sexual contact towards a therapist who has already said in the last episode "I'm you're therapist, I'm not an option." Makes it hard to go on.

My post to Anonymous of "You Don't Have to Say it All" wasn't a criticism of either her feelings or her presentation of them (I wasn't in the room sub-blogging for that episode!), it was simply meant to say that it is possible for a psychotherapy to be useful even if there are somethings that a patient doesn't fully share with a therapist. Some things aren't relevant, and some things can injure a psychotherapy relationship to the point that a poor human doc would just have a rough time continuing (...oh, for extreme make-believe example: "You know I'd never do it doc, but I have pretty constant fantasies about wanting to rape your 6 year old daughter"--)

And there are gentler ways of caging feelings about the relationship. "This is really uncomfortable to talk about, but I find myself attracted to you, and maybe it would help to discuss it." Still uncomfortable, but a far cry from saying to one's therapist/doctor/etc, "I want you to F**K me."

Anon's comment was simply a spring board, I'm sorry if I seemed to be responding to it rather than the TV fiction.

dinah said...

Another thought:
I'm not sure if Anonymous is a him or a her. Or that it matters, but he might have been a him.

DrivingMissMolly said...

Carrie and Alison, you are spot on.

Dinah, you are the therapist you are the one in control. I have done some research into "erotic transference," and the best information I found is on the website http://www.guidetopsychology.com. by Doctor Robert Lloyd Richman, a psychologist. according to him, many practitioners don't know what to do with erotic transference or fear it, become uncomfortable, etc. He says that the exploration of erotic transference can be a powerful tool in therapy. No, I don't mean acting on it : )

I agree. I think your strong negative reaction is counter-transference, Dinah. This is about YOU and not the patient.

Granted, I agree that the woman in the episode (I haven't seen that one yet) you referenced is crass in her attempted "seduction" of the therapist, but it just occurred to me....could there be an issue from her past that is causing this behavior? Narcissism, yes. Borderline traits, possibly. Could she have been molested, raped, sexually abused...? Hence, could she have no sense of boundaries?

I know that the reason that he needs to terminate her is clear...and it is that he cannot handle the erotic transference, but more importantly, he cannot handle his counter-transference which makes HIM vulnerable to her advances. He is, after all, having problems in his marriage, and his sex life, correct? One cannot underestimate a keen smart patient who picks up on the vulnerabilities of a therapist even if they are not spelled out.

I know that if I said what she said to her therapist to MY therapist, he'd deal with it. He is unflappable. It would be out of character to say something like that to him and he would know that since I have been seeing him for 5 years, but he would handle the situation and not freak out. Luckily, I have never had those kinds of "feelings" for him for any sustained period of time. Maybe it is because he speaks of his wife quite a bit and so I feel like I know her and I would never want to hurt her. I also respect the wedding ring, but many, many women don't. I will admit a fleeting time when I had a fantasy involving him, but when I analyzed it myself it came down to this: YOU DO NOT FALL IN "LOVE" WITH YOUR THERAPIST OR PSYCHIATRIST, YOU "FALL IN LOVE" WITH BEING LISTENED TO AND TREATED NICELY AND WITH RESPECT! Some of us have NEVER gotten that and it makes a person attractive to us. Thus, the real tragedy is that terminating this woman reinforces what she has gone through in her life. Don't say what you feel, you will be judged. She will also not learn about appropriate boundaries, just about more rejection.

Physically, however, Therapist is a genius, but possesses a non-descript, non-hot appearance, and that helps. : )

My psychiatrist is very attractice. I think he is beautiful. I'd never seen a beautiful psychiatrist before. I respect the ring, and fortunately, I respect myself enough to NOT do something unseemly. I do, however, think he could handle it if I said something sexually forward. I recognize that my fantasies about him holding me on his lap and telling me I'm a "good" girl, have nothing to do with sex and everything to do with my "daddy issues."

Maybe it is the appeal of the "forbidden" that gets women going. Remember the movie about the woman and the priest falling in love and getting it on?

The forbidden, a priest, a married man, a psychiatrist or therapist, I suppose it can be as tempting as, well, an apple.

Lily

Gerbil said...

Alison, you ask "Why does it have to be transference when the paid professional has an MD?" (Of course, it doesn't have to be an MD...)

The word "transference" is psychobabble--and I'm using that term in an objective, not a judgmental, sense. It has a very specific meaning for psychotherapy, but that doesn't mean the concept doesn't exist outside of session. For example, it's really, really common to react to your significant other in the same way you react to one of your parents. Although you might not realize this without an outsider's perspective, it doesn't make you stupid. It makes you human.

And you're right, it's unfair to assume that anything that goes "wrong" in a therapist-client relationship is the client's fault. The therapist's countertransference (his/her reaction to the transference) is just as important in this regard as is the client's transference. Ideally, the therapist will be aware of both the transference and the countertransference, and bring each up as appropriate.

I would also argue that there's very little that can go "wrong" in the therapeutic relationship if there's no sex, manipulation, otherwise unethical or illegal behavior, or boiled rabbits to speak of. There are certainly therapists out there who ought not to be therapists, but I also think that there are many instances where the relationship can (and should) be repaired.

Incidentally, there is an interesting article by Stiles et al (2004) on the rupture-repair hypothesis of alliance development. They found that clients with "v-shaped" therapeutic relationships (with brief disruptions that were quickly repaired) tended to make more gains in treatment than other clients.

dinah said...

Lily:

Watch the episode! You can download it on hbo.com. This is like trying to diagnose a patient without meeting them.

And thanks for the idea for the next post.

I am so waiting to be in control of something in my life.

Alison Cummins said...

Thanks, Dinah, it makes sense that you were talking about Laura (aggressive and threatening) and not Anonymous (neither of us know).

So thanks for clearing that up.

(And yes, Anonymous sounds very much like a man, but I don’t like to make assumptions. Which is why I didn’t use any gendered pronouns when referring to Anonymous, just to the therapist who we know is a woman.)

DrivingMissMolly said...

Dinah,

Yes, yes, yes! I watched it since I posted and many of my thoughts were brought up by Gina, as played by the wonderful Diane Weist. Boy, they have a history, those two!

There are a lot of things I like about Laura. She is intelligent, funny, and she tests Paul. OMG! That is my psychiatrist's name....that just ocurred to me.

OK, well, right now, what with what is going on in Paul's life, he does need to get Laura transfered to another therapist. It's just, as a patient, I would hate to start over with someone else after a year. It seems unfair. I definitely do NOT want to see Paul and Laura make the horrible mistake of "hooking-up," as the kids like to say. BTW, LOVE LOVE LOVE Sophie.

Anyway, Dinah, I love these discussions and think they are quite relevant. I think anytime your profession is portrayed to the public, it should be up for discussion because people will believe certain aspects of the portrayal.

Did you know Paul's a psychoanalyst?

I see a lot of myself in Sophie. At first I though of myself more like Laura, but I don't have that kind of confidence. "I can tell when someone wants me, Paul." WoW!

Unforch, the episodes on the Internet are edited, but I hope to catch the original versions at home.

Love ya!

Lily

PS This reminds me...I need to make an appointment...

Alison Cummins said...

gerbil,

“[I]t’s really, really common to react to your significant other in the same way you react to one of your parents.”

Sure. Acknowledging that can help someone who is trying to figure out why they overreacted. Absolutely. Yup yup yup.

But still, there’s usually something to build on. Transference could be a fancy name for “Once bitten, twice shy” or “Chat échaudé craint l’eau froide.” (A cat that’s been scalded fears even cold water.)Generalising from experience.

Or it could mean Vanna White-type projection. She’s one of the most popular TV personalities of all time: she smiles, doesn’t say anything and gives things away. What’s not to like?

If a therapist is really irritated by a client, maybe it’s that the client is really irritating. Why should it have to be labelled “countertransference”? If clinkshrink were to be threatened by a knife-wielding inmate, would her feelings of fear and anger be “countertransference” simply because she is a shrink, while everyone else would get to feel angry and afraid?

Not saying there are never reasons to isolate transference as a topic of discussion or a method of approach to a problem. But use of that kind of vocabulary can be used (cynically or innocently) to distract from the immediate facts of a situation (such as, someone is behaving in a threatening way).

I’m particularly annoyed by “countertransference.” If transference is simply transfering responses learned in one situation to another, then it should be a perfectly good word to use about therapists. But for some reason, it’s not.

Sarebear said...

I think they use it so it doesn't get too confusing when discussing the matters, so you know whose transference you are talking about.

I agree with Allison that transference can or could be used to dismiss something, but I also really like what Gerbil had to say and agree with that.

This is all after the latest post on Weds. Afternoon, which clears things up even more, but I hadn't read most of these responses. Interesting discussion.

As long as transference is being discussed, can I have a bank transfer? Money is good (hee hee!).

ladyak47 said...

It is important to understand transference, but in the end, a clinical relationship is two people in a room. Being the therapist is a role you play. Just like other roles people may have in life. As a therapist my job is about listening, observing, thinking, and helping.

It is easy to fall in love with someone who is helping you.

Today an individual with mental illness and the beings of demenia wnet up to me and hugged and kissed me on the check. I just calmly told him that kisses staff is not appropriate. End of the issue.

I do have to be careful with some of my clients. I intern at a day treatment center with many different programs. Some of my clients are violent offenders. If someone with that sort of history talks to me in sexual overtones in can be a serious issue.

TherapyPatient said...

I agree with Alison Cummins comments. I dislike the term transference and feel it's a way to dismiss what I see as genuine feelings.

I have been feeling "in love with" my psychiatrist and several friends have told me it has to be "transference". I have read everything I can find on the internet about transference and feel that it's unfair and inaccurate to say that my feelings for my psychiatrist are the result of "transference". Even though the relationship is "theraputic" and he is paid to talk to me, he is is the most kind and understanding person I have EVER had in my life. He's non-judgemental. He really deeply understands what I tell him, and has amazing insight. We joke and laugh and have a most incredible counseling relationship. I feel that my warm, loving feelings towards him derive from the way he treats me and are deserved and appropriate because he is so kind, understanding, and perceptive. It is REAL.

To compound my difficulty in understanding how what I feel for him can be "transference" is that my parents were abusive and unpredictable. I feared my parents especially my father. When I STARTED in therapy with my psychiatrist I was afraid of him. THAT I could understand might be regarded as transference. That I feel "love" for my psychiatrist now, doesn't seem as though it COULD be transference of what I felt for my parents since the home environment was so difficult and scary for me.

I KNOW there can never be an actual relationship with my doctor outside the office, but still I am very emotionally attached to him. The emotional attachment is very uncomfortable however, BECAUSE I know that this is not a "real" life relationship that can develop into something, and because I know that eventually my therapy sessions will end and I won't have him in my life. That thought gives me pain, worry, and concern. I am dating men and I find that I compare the men I date with my therapist and it's a disappointment that the men I AM able to have in my life don't seem to measure up to my therapist, and there's a strong possibility that I will NEVER find a mate that WOULD measure up to my therapist. As a result of both these things I find it painful that I AM so "in love" with my psychiatrist.

I DID bring the topic up with my psychiatrist, and I was glad that HE did not invoke the word "transference". He said it's very natural to feel "love" when someone is very kind to you and they understand and empathize. He said we have a very special relationship . (He is NEVER inappropiate and always 100% professional and he did not mean this in any inappropriate way). He also said I don't HAVE to end therapy. However, just from a cost standpoint (twice a week at $180 a session) I know I can't AFFORD to see him for the rest of my life, and truly I hope to not "need" him forever.

My feelings of love and dependence on my psychiatrist have added an aspect of pain to my life (can't have him/never will/eventually must leave him) that I never anticipated when I started therapy. The plus side is that he's helped me clear some major hurdles in my life, I have learned to communicate feelings better, and have much greater insight into myself. The changes he's helped me make are amazing.