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NT: What do you recommend as self-care for therapists, to prevent themselves from acting out in this way with their clients?

GG: There are several self-care measures that are essential. First, therapists must build leisure time into their schedules. I know therapists who see their first patient at 5 or 6 am and don't go home until 8 or 9 pm. Work is their life. They have no time for social or emotional relationships so they begin to look for gratification of those needs with their patients. Second, therapists must work on their close personal relationships to build them, sustain them, and nurture them so they feel fulfilled by them. Third, therapists must not attempt to solve all problems by themselves out of a sense of pride or rugged individualism. We should all be using consultants as colleagues throughout our careers-no matter how skilled we are. I regularly use consultants for my cases.

NT: Is it your experience that therapists only come to you after having acted out? One would imagine this to be the case since any therapist who acts out will at the same time be likely to believe it is the right or necessary thing to do. Why is this phenomenon so ego syntonic?

GG: No, some therapists come before they have become sexually involved with a patient. Having said that, I would also point out that there is a "point of no return" after which the therapist will not seek consultation because he/she doesn't want to be stopped. Many therapists have come to me over the years, knowing that they are in deep trouble and stopped themselves before acting on the siren song of sexual desire. On the other hand, our capacity for self-deception is extraordinary. I would not say that this type of acting out is generally ego syntonic. In cases where the therapist is not psychopathic, he/she is usually conflicted about what is going on and desperately begins to rationalize that in this particular case, he/she is an exception to the usual ethics guidelines. Many deceive themselves into believing that there is nothing harmful or exploitative about their actions.

NT: Because of the unique nature of each emergence of an erotic therapeutic transference, it would no doubt be ill advised and difficult to make blanket recommendations about how these might be handled. However, what guidelines would you offer analysts about the following dilemmas and questions with a view to most effectively using and managing the erotic transference:

Firstly, what are your thoughts about the disclosure by the therapist of his or her own countertransferential thoughts and/or feelings to the client, particularly when these are of a sexual nature;

GG: Disclosing sexual feelings of the therapist for the patient is often disastrous for the treatment. It tends to shut down the "play space" and make the therapeutic setting suddenly "real". I have seen many patients who say that the therapy ended at the point the therapist disclosed sexual countertransference. It frequently is a forerunner to sexual boundary violations. It is especially problematic if the therapist is male and the patient is female, but any gender constellation can be equally disastrous. Jody Davies published a case where she disclosed sexual feelings to the patient but managed to continue the treatment. So it may be possible in rare instances, but I would strongly discourage it.

NT: To what extent ought the therapist to interpret the erotic transference as a resistance to the treatment;

GG: As you imply in the question, the answer to this depends on the particulars of the therapist/patient dyad and process. However, erotic transference as resistance should certainly not be construed as an obstacle to be eradicated. A more modern view of resistance is that it is a revelation of an important internal object relationship that should be understood and explored.

NT: How advisable is it for the therapist to encourage the client to explore in greater detail the contents of their erotic fantasies.

GG: This question also depends on the particulars of the dyad. The way that one explores erotic transference can be as important as whether or not one does it. If the patient experiences it as primarily for the therapist's voyeuristic interest, the patient can feel exploited and demeaned. If the patient experiences it as an exploration for the purpose of understanding the patient's internal world, it can be productive.

NT: In the immortal words of Jimmy Ruffin: "What becomes of the broken-hearted?", one might ask: "What becomes of the broken therapists?" Where do they go? How do they carry on? How do they integrate their transgression? This takes us back to the first question about the "confessional". What does the therapist who has seen you go away with? What is the conscious and unconscious "deal" inherent in this confessional matrix?

GG: The answer to this series of questions is complex. There are a myriad of possible outcomes depending on the therapist's recognition of the problem and the licensing board's propensity for treatment vs. punishment. The majority of cases I have seen are sent to me by licensing bodies, and a report is sent to them. Hence some therapists lose their license and seek employment in alternative careers. Others are placed in rehabilitation programmes and regain their ability to practice. Still others don't think they have done anything wrong and are not amenable to rehabilitation. A substantial number are deeply remorseful and dedicate themselves to avoiding future transgressions. I know of several who have now returned to practice for many years without having subsequent boundary violations. Most therapists go away from seeing me with a renewed understanding of the dynamics that led them into self-destructive behaviour, a grasp of which patients are likely to be high risk for them, and a sense of how to work their way out of the hole they have dug for themselves.

NT: Freud commented that "the process of cure is accomplished in a relapse into love". If Freud was right, it might be argued that the "love" reaction in clients is to be strongly encouraged when it occurs. Many therapists appear to hold this view and are very encouraged when a client confesses an erotic transference. What is your response to this apparently strong belief in the importance and power of the erotic transference?

GG: Times have changed since Freud. We now know that all patients do not fall in love with the therapist. Erotic transference may or may not occur. It is more accurate to say that the patient's habitual mode of object relations will be repeated in the therapeutic setting. Hateful patients will hate the therapist. Narcissistic patients who have problems loving others will have the same problems with the therapist. It may or may not be a good sign if erotic transference develops, and I certainly wouldn't encourage it. That can lead the patient into a false self-compliance.

NT: In the last 20 years or so, have you observed any significant movements in the way in which psychoanalytic theory views how the therapist or analyst should work with the erotic transference?

GG: I would say that the overarching transformation in the way erotic transference is understood during the last two decades is this: we now regard therapy as a two-person phenomenon where patient and therapist co-construct the transference. In other words, the therapist continually contributes to the patient's transference in ways that are beyond his/her awareness. There are many reasons that therapists wish to encourage erotic transference, and they need to be vigilant about how they are subtly encouraging it.

NT: Under what circumstances would you recommend that the therapist terminate work with a client in the presence of strong erotic transference and/or countertransference?

GG: I would first talk to a colleague who is knowledgeable about transference and countertransference in a formal consultation. I would share openly and honestly all the fantasies and concerns you are having about the patient and the process. If you feel that your capacity to think or to help the patient is compromised, and the consultant agrees, I would terminate the therapy and refer the patient to another therapist with a clear understanding that you will not see the patient again (either professionally or socially).

Terri Broll is a Clinical Psychologist in private practice in Pietermaritzburg, South Africa.

John Söderlund is a Counselling Psychologist in private practice in Pietermaritzburg and publishing editor of New Therapist.

Susan Spencer is a Counselling Psychologist in Pietermaritzburg and contributing editor of New Therapist.

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