The Conflicting Levels of the Psychoanalytic Relationship

Revisiting Controversies over Authenticity versus Professionalism (Vol. 1, Issue 44)

Recently published psychoanalytic journals rarely contain discussions of differentiating the psychotherapeutic relationship from other ones running in parallel. Before the millennium, debates raged over transference, working, and real psychoanalytic relationships. Could a real relationship exist alongside the professional one? Some highly conservative psychoanalysts, like Robert Langs (2005), thought not. He insisted upon almost an absurd levels of abstinence, neutrality; he advised strict boundary maintenance. Changes in psychoanalysts’ hair styles, mode of dress, or even office furnishings should never change, he thought. Clinicians must maintain the steadiest possible frame for patients at all times.

The rise of the three major contemporary schools—self-psychology, intersubjectivity, and relational psychoanalysis—heralded a welcome end to these distinctions and to the rigidity associated with them. However, while acknowledging the impossibility of keeping these interpersonal roles from overlapping, the more interpersonal trends brought confusion. A recent experience with a long-term patient, who expressed feelings of guilt and shame regarding her degree of intimacy with me, a married man, led me to reflect further on these themes.

The patient, a 55-year-old woman named Lillian, has been consulting me for more than 20 years, except for a few short breaks. She has consistently worked as an administrative assistant for a manufacturing firm. Educated in the Catholic Church, Lillian attended classes in a convent through high school. Years later, she identified herself more as a Protestant, but the influence of Catholicism lingered. Lillian wonders if, along with the recent emergence of guilt and shame, she might be sinning.

Quick side point:

At various times, Lillian has also expressed concern about the unusually long length of our relationship. Her middle-aged son, for example, criticized her for meeting with me for so many years. His critique, combined with a judgmental character in her unconscious internal drama, occasionally elicits doubts. Around once a year, we revisit the topic of the value of our meetings. So far, anyway, these discussions end with her concluding the sessions have been helpful, and her motivation for continuing sincere.

Lillian veered into a different type of shame when she recently raised the issue of my marriage. On the one hand, she believes our meetings have increased stability of her sense of self. She has developed a greater capacity to identify and negotiate for her own needs. As you readers would expect, we have spent many sessions reviewing her marital relationship, which ended in divorce. We have discussed several of her long-term romantic relationships since then. Lillian understands, more than ever before, the difficulty achieving authentic, intersubjective intimacy. Lillian has come to realize she leaned towards the masochistic in past relationships. She tended to defer to the interests of men with whom she became romantically involved.

On the other hand—and here comes an elaboration of her shame and guilt—Lillian considers our relationship as the most emotionally intimate of her life. She is afraid her transient feelings of competition, jealousy, or possessiveness might negatively impact my wife (whom, of course, she has never met). Most significantly, she worries about sin. She wonders if her intimacy with me constitutes a sin. The topic has dominated our discussions for the past few weeks.

Interestingly, the two threads, one the positive, growth-related assertiveness, and the other, concerning competitiveness and harm, intertwine with one another. Individuals in long-term relationships of any type—whether bound by romance, friendship, or blood—must learn to negotiate (Aron, 1996). If not, they inevitably slide into some variation of relationship sadomasochism. Apparently a phrase oft-uttered by Canadian psychologist Jordan Peterson, and bluntly put, intimate couples either become proficient in negotiation or the parties to them assume tyrannical or slave-like roles.

By her own admission, Lillian lacked sound interpersonal skills until she was in her late 40s. We worry, together, if the intimacy of our relationship serves a defensive function for her. Why enter the dating scene when she feels so understood by me? Perhaps our relationship indeed provides her with sufficient need satisfaction to make it easy to avoid the discomfort of dating.

As often occurs when composing this newsletter, this topic opens a vortex of potentially infinite themes. Subjects other than intimacy in psychotherapy relationships, or the wisdom of long-term work, flood my thoughts. Perhaps depth therapists should set an advance termination date—as some do—to prevent excessively lengthy psychotherapy relationships. A discussion of the degree of psychotherapist self-disclosure seems relevant. Feeling constrained by the critique that these newsletters can, themselves, become excessively long, I shall focus on the specific topic of the levels of psychotherapists’ relationships with their patients. At some later date, I will certainly address the other, related topics.

I proceed with a microscopic focus, then, on where the so-called real relationship ends and the professional one begins. Along the way, I shall address Lillian’s questions of intimacy and of sin.

In the early days of psychoanalysis, clinicians were encouraged to behave like surgeons treating anesthetized patients. Such neutrality completely avoided psychoanalysts’ complicity in developing the type guilt and shame troubling Lillian. Or, more accurately, they allowed them to at least consciously avoid responsibility. Making specific recommendations for psychoanalytic practitioners, Freud (1912) wrote:

I cannot advise my colleagues too urgently to model themselves during psychoanalytic treatment on the surgeon, who puts aside all his feelings, even his human sympathy, and concentrates his mental forces on the single aim of performing the operation as skillfully as possible. […] The justification for requiring this emotional coldness in the analyst is that it creates the most advantageous conditions for both parties: for the doctor a desirable protection for his own emotional life and for the patient the largest amount of help that we can give him to-day (p. 115).

I vehemently disagree with him, and never was, even during psychoanalytic training, able to pull off such neutrality. Instead, I navigate the treacherous waters between the personal and the professional with as much care as possible. I am a real person to patients. At the same time, and as I advise students of the depth therapies, I never lose sight of the fact that we practitioners are selling a service. We facilitate personal, transformational encounters. Herein lies the rub: These encounters only work if they are intimate enough to dislodge patients’ relationships with their unconscious internal dramas.

The intensity of psychoanalytic encounters requires an almost revolutionary fervor—captured by Fairbairn’s (1952) quip, "perhaps the psychoanalyst is really rather lucky to get away with a whole skin when he invites human beings to inspect their own motives” (p. 249). The psychoanalyst-patient bond must be intense enough to loosen the familiar, habitual, addictive-like nature of patients’ internal dramas. Fomenting these personal revolutions requires an establishment of trust, a strong interpersonal alliance, even love. An intense psychotherapist-patient partnership facilitates clinicians work to disturb, disrupt, unsettle, agitate, or otherwise tamper with these well-worn intrapsychic and interpersonal patterns.

Errors can be identified, rather easily, at either end of the psychotherapy relationship continuum. Like many others before me, adhering to the “Gemini twins of abstinence and neutrality” (Davies, 1994, p. 156) damages patients. They are treated in a cold, distant fashion (interestingly not achieved even by Freud in his actual work). It harms patients regardless of their attachment histories.

Nonetheless, I can, on occasion, feel envious of those clinicians capable of such aloofness. The concerns haunting Lillian might emerge anyway, but at least a more distant psychotherapist would not participate, at least consciously, in the intimacy with which she feels uncomfortable.

One of my colleagues, an ardent Kleinian, took off his wedding ring while divorcing his wife. He told his patients nothing. When, and if, they noticed the absence of his ring, he asked them to share their thoughts and fantasies. He never spoke a word of his separation, divorce, or subsequent remarriage. The tactic is crystal clear, unassailable.

A different set of problems plague the more liberal relational practitioners (Mills, 2005, 2012). If psychotherapeutic relationships become too personal, a variation of rent-a-friend, their facilitative role disappears. Sexuality, or overt displays of aggression, signify obvious excesses. These constitute actual boundary violations, rather than boundary crossings (Gabbard, 2016). In other words, and diametrically opposing the psychoanalyst-as-surgeon method, straying into actual and prolonged personal and mutual intimacy is unequivocally problematic. Many pioneers in the field, including Jung and Ferenczi, blurred the boundaries in these ways.

Finding the middle-ground proves difficult. However, Lillian is hardly unique in finding her relationship with me her most intimate. Depth therapists often wrestle, like me, with finding their way between the two obvious extremes. I no longer remember when I first advised Lillian of my marital status. It was years ago. Over the years, she has learned also of my two daughters, my one grand-daughter, and my medical misadventures.

When practitioners choose to behave authentically with patients, an endless dialectical game begins. They strive to be genuine while, paradoxically, remaining professional. Few hard and fast rules apply. Ethical practitioners maintain the commonly known boundaries. They avoid the extremes of sexuality and aggression. Navigating the tension between being real and being professional requires skill. Clinicians need to stand at-the-ready to improvise (Ringstrom, 2018) in responding to their patients’ as well as their own situations. When facing illness, conflicts in their own relationship, or excessive stress, vigilance is required. The work is edgy, validating that practicing psychoanalytic psychotherapy is just that—a practice, a work-in-progress, an unfolding process.

As noted, the extremes of behaving like blank screens or like lovers are easy to identify. Obviously, I advocate for the middle road. Along these lines, consider more subtle situations. If I shared details of my marriage, particularly the difficult times, one could legitimately consider my behavior as seductive. But what if I were single? Or divorced? My relationship status will impact Lillian, no matter what. Obviously, it would affect other patients as well.

Another helpful talking point, specifically in my meetings with Lillian, concerns the bounded nature of all relationships. Thomas Szasz (1988) believes all relationships are contractual. Married people obviously consent, at least consciously, to abide by certain restraints. Friendships have boundaries, and so do associations with kin. Lillian and I discuss the typical boundaries between parents and children, and vice versa. We study the contracts in her various relationships. These have also become means of managing her discomfort with the intimacy in our relationship. Ours is certainly intimate, yes, but with boundaries and limits.

In conclusion, I find reassurance in an emphasis on psychoanalysts’ facilitative role. Regarding Lillian’s recent concerns, the most important intervention concerns the continued emphasis on self-exploration for her, not for me. Explorations of her competitiveness, envy, and aggressive fantasies have proved extremely valuable. How could Lillian learn to negotiate better if not able to identify, express, and manage strong feelings? The safety of the consulting room provides the growth-inducing crucible for her.

Regarding her concerns over sin, I particularly emphasize her thoughts and feelings. Psychotherapists strive to avoid value judgments. A few years ago, when Lillian entered similarly troubled waters, she consulted a priest. I endorsed the idea. He found no sinfulness in our long term therapy relationship. By showing my genuine curiosity about her concerns, accepting their legitimacy, and encouraging further introspection and discussion, Lillian moves through her life with increased confidence and ease. The recently emergent feelings of guilt and shame, as well as the concerns over sin, are receding.

Apologies for reprinting a quote used previously, but it provides a fitting punctuation for points made thus far. Adam Phillips, as reported in an interview described by Choder-Goldman (2014), said:

I think if people don’t care about each other, nothing’s going to happen, and if people aren’t moved by each other, nothing is going to happen. (p. 342)

Care, involvement, engagement, feeling moved, are certainly required. And, yet, as Aron (1996) portrays with his phrase, “mutual but asymmetrical” (p. 43) intimacy, psychoanalytic practitioners remain responsible for the asymmetry. Perhaps here, finally, a hard and fast rule exists. However clinicians manage the dance between the real and the professional, they hold the reigns when it comes to maintaining the frame.

References

Aron, L. (1996).  A Meeting of Minds: Mutuality in Psychoanalysis. Hillsdale: The Analytic Press.

Choder-Goldman, J. (2014). An Interview with Adam Phillips. Psychoanalytic Perspectives, 11(3):334-347.

Davies, J.M.  (1994).  Love in the afternoon: A relational reconsideration of desire and dread in the countertransference. Psychoanalytic Dialogue, 4, 153-170. doi: 10.1080/10481889409539011

Freud, S. (1912) Recommendations to physicians practicing psychoanalysis. Standard Edition, 12:109-120.

Gabbard, G.O. (2016).  Boundaries and Boundary Violations in Psychoanalysis. Second Edition. Washington, DC: American Psychiatric Association.

Langs, R. (2005). The technique of psychoanalytic therapy. (Volumes 1 and 2). New York: Rowman and Littlefield. (Original work published in 1973).

Mills, J. (2005). A Critique of Relational Psychoanalysis. Psychoanalytic Psychology, 22(2):155-188.

Mills, J. (2012). Conundrums: A Critique of Contemporary Psychoanalysis. New York: Routledge.

Ringstrom, P. (2018). Three dimensional field theory: Dramatization and improvisation in a psychoanalytic theory of change. Psychoanal. Dialogues,28:379-396.

Szasz, T. (1988). The ethics of psychoanalysis. Syracuse: The Syracuse University Press.