But is it love?

An interview with Glen Gabbard

 

Questions by Terri Broll, John Soderlund and Susan Spencer

Introduction by John Soderlund

"In psychoanalysis everything boils down to sex, doesn't it," a client recently remarked.

My client's crass characterisation of the discipline aside, the frequency with which sexual issues arise within the therapeutic setting certainly suggests therapists spend their fair share of time mulling over the carnal.

Internationally renowned psychoanalyst Glen Gabbard probably discusses sex with his clients no more than the average analyst. But few others can claim that a relatively large proportion of the clients with whom they address issues of the flesh are themselves therapists-therapists who have transgressed the most sensitive ethical no-no in the profession: No sex with clients.

Gabbard talks to New Therapist about his work with these clients and the lessons he has learnt about what happens when psychotherapists let therapeutic relationships boil down to little more than sex.

NT: In many ways you seem to have a unique position in the analytic community, almost a Father Confessor to "sinning" psychoanalysts. You have written prolifically and creatively on the boundary violations that have been "confessed" to you and fed this back to the analytic community in a way that helps and advises others in similar situations, but you haven't written about what it is like to be in the role that you are in. Inadvertently, one might say, psychoanalysis (the original secular confessional) has introduced the "confessional" into it's own midst. What are your thoughts on this?

GG: I had never thought of myself in the role of father confessor, but you are correct that my interactions with therapists who have transgressed boundaries often take on the cast of a confessional. Fortunately, this is a small part of my work. In a typical work week, most of my time is spent seeing patients who are not involved with boundary violations, teaching and supervising candidates, psychiatric residents, psychology interns, and social work interns, editing the International Journal of Psychoanalysis, and writing books and papers. Once a week I lead a three-day evaluation of a patient who has been referred to me from elsewhere. Many of these are professionals who have committed boundary violations.

These assessments can be emotionally trying, but it helps that I conduct them in the context of a multidisciplinary team so that conclusions are reached in a team meeting after the evaluation is completed. This process keeps countertransference in check to some degree, but I still have to deal with the tragedy of a damaged patient and a ruined colleague. It takes its toll on me to contain the powerful affects generated by this work, so just as Winnicott said he would only treat one borderline patient at a time, I carefully titrate the number of these patients I see in a typical month so that I do not become drained or overwhelmed. I also take great care to avoid a forensic role in which I would have to testify in a courtroom situation or give a deposition. I find the reduction of the complexity of these situations into black-and-white, good-and-evil, right-and-wrong extremely destructive. Hence I will not evaluate a case if the referral source wishes to have me testify. The other impact the father confessor role has had on me is to appreciate how fragile and vulnerable we all are to the siren song of a suffering patient who longs to be rescued. We work in a field with an ever-present occupational hazard that requires extraordinary self-discipline and eternal vigilance.

NT: In your work with other therapists who have transgressed sexual boundaries with patients, what are some of the key behavioural or emotional markers that point to an eventual collapse of the therapeutic feelings into an unethical acting out of sexual energy?

GG: If we exclude the psychopathic predators from consideration, we can focus on two pathways that lead to sexual boundary violations. One is the lovesick therapist. He is usually, but not always male. He is depleted because of severe stress in his life-divorce, a dead marriage, bankruptcy, a malpractice suit, severe illness in spouse or children, for example. He finds himself daydreaming about his patient, who seems to offer some salvation for his despair. He begins to self-disclose his personal suffering to the patient, and a role reversal occurs. The sessions start to shift in focus in such a way that the patient comforts him. Then he begins to think that his case is an exception, and he can violate boundaries without serious consequences. The descent down the slippery slope begins. He stops charging a fee. He begins to hug the patient. He extends the hour. He meets the patient outside the office. Soon they are in bed together.

If the lovesick therapist is female, then the scenario is slightly different. With a male patient, the therapist begins to think that a Cluster B personality disorder patient (who is often a substance abuser) is not as bad as he seems. Despite criminal behaviour or exploitative treatment of others, the patient is seen as a "baby" who needs the love of a good woman to settle him down. She starts going to extraordinary lengths to rescue him, while he encourages her to take care of him. She falls in love with him and becomes blind to his true nature as she is swept off her feet. If the patient is female, a straight female therapist may be drawn into a similar rescue effort even though she thinks of herself as heterosexual. She may focus on the love and the physical affection without thinking of it as sexual. In gay therapists, these same scenarios are typical.

The other variant for both straight and gay therapists is the masochistic surrender scenario. A worried therapist is terrified that a patient may commit suicide. The patient starts accusing the therapist of not caring. The therapist goes to great lengths to demonstrate his/her caring by allowing the patient to dictate the conditions of the therapy. Soon the patient is in control of the therapy and the therapist is afraid to set limits for fear that the patient will commit suicide. The patient demands physical displays of affection that eventually become sexualized. In all scenarios, deviations from one's usual way of working are the first signs of trouble.

NT: No doubt some of these therapist transgressors with whom you have worked believed on some level that their feelings were "the real thing", that they constituted the early stages of a potentially sustainable love relationship with their clients. Do you think these feelings could ever be "the real thing" and why? Is being "in love" ever the real thing?

GG: Your question is a good one because what I have heard countless times when evaluating therapists who have become sexually involved with their patients is some variation of this: "You don't understand, Dr. Gabbard. What we have between us has nothing to do with transference or countertransference. It is true love. We are soul-mates. We were destined to find each other. We just happened to be in the roles of therapist and patient when it happened."

The folly of statements like this is simple. None of us can tell the difference between the love that occurs in therapy and the love that occurs outside of therapy. We are always re-creating old relationships in the present. Freud said the finding of a love object is a "re-finding." The point here is that love occurring in the therapeutic setting begins in the context of a power differential and a fiduciary relationship where one pays another a fee for a service.

It is exploitative to take advantage of the patient's vulnerability by professing love and becoming sexually involved. Love is entirely irrelevant to questions of ethics. Boundary violations of ethics codes are all about the behaviour of the therapist not about the genuineness of the internal motivations. Moreover, love in the therapeutic setting is frequently a defensive posture against hate, contempt and anger.

Continued on next page ...

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