Papers

Sexual Excitement in Therapeutic Relationships:
Clinical and Supervisory Management

Nancy A. Bridges, LICSW, BCD
Janet W. Wohlberg, MS, ABD 

All therapists at some point struggle with sexual and loving feelings in therapy relationships. Due to the absence of core curriculum on the resultant treatment issues, the psychotherapy supervisor or consultant may be the primary clinical teacher around these complex clinical situations. A safe, shame-free, trust-worthy supervisory relationship provides the arena for open dialogue, self-revelation, and deep clinical exploration of these issues.

Despite ethical prohibitions, legal sanctions, and increased professional and consumer awareness, sexual misconduct between psychotherapists and patients continues to occur (Blackshaw & Patterson, 1992; Carr, Robinson, Stewart, et al, 1991; Dehlendorf & Wolfe, 1998; Gartrell, Herman, & Olarte, 1986; Gartrell, Herman, & Olarte, 1988; Gartrell, Milliken, Goodson, et al, 1992; Gechtman, 1989; Robinson & Reid, 1985; Schoener, Milgrom, Gonsiorek, et al, 1989). While psychotherapists of all disciplines often encounter sexual and loving feelings in therapeutic relationships, specialized curricula addressing their management are generally absent from graduate course work and clinical training programs despite wide support (Blackshaw & Patterson, 1992; Bridges, 1995; Carr, Robinson, Stewart, et al, 1991; Gabbard & Lester, 1995; Gorton & Samuel, 1996; Gorton, Samuel & Zebrowski, 1996; Rodolfa, Kitzow, Vohra & Wilson, 1990; Roman & Kay, 1997). This neglect of in-depth teaching and supervision around the therapeutic relationship, and transference and countertransference phenomena, may be due in large part to current mental health policies that emphasize cost containment and limiting treatment services, and to resultant training programs and internships that are heavily biased in favor of biological and brief treatment models (Bridges, 1995; Gabbard, 1996; Gorton, Samuel & Zebrowski, 1996; Rodolfa, Kitzow, Vohra & Wilson, 1990; Roman & Kay, 1997).

Lack of specialized training leaves clinicians vulnerable to misunderstanding or mishandling sexually charged clinical situations. With inadequate preparation, clinicians run the risk of engaging in destructive behavioral enactments or developing restricted practice styles that stunt the psychotherapeutic process (Adrian, 1996; Blackshaw & Patterson, 1992; Bridges, 1995; Carr, Robinson, Stewart, et al, 1991; Gartrell, Herman, & Olarte, 1986; Gartrell, Herman, & Olarte, 1988; Gartrell, Milliken, Goodson, et al, 1992; Gechtman, 1989; Gorton & Samuel, 1996; Gorton, Samuel & Zebrowski, 1996; Robinson & Reid, 1985; Rodolfa, Kitzow, Vohra & Wilson, 1990; Roman & Kay, 1997). Additionally, the absence of formal curricula often places the preparation and education for erotic aspects of psychotherapeutic practice on supervisors, many  of whom feel inadequately prepared to deal with sexual feelings and resultant complex treatment situations (Bridges, 1995; Gabbard, 1996; Gabbard & Lester, 1995; Gorton & Samuel, 1996; Gorton, Samuel & Zebrowski, 1996; Pope, Sonne & Holroyd, 1993; Rodolfa, Kitzow, Vohra & Wilson, 1990).

This paper, which includes a case and analysis—written collaboratively by a psychotherapist, who teaches and consults on erotic transference/countertransference, and a victim-survivor of sexual abuse by a psychiatrist—is an amalgam of incidents from actual cases and supervision. Events have been integrated to avoid problems of confidentiality. The paper is intended to be used as a clinical teaching vehicle for psychotherapists-in-training, practicing psychotherapists, and psychotherapy supervisors. Recognizing the general self-consciousness often associated with revealing and discussing sexual feelings from or toward patients, the authors’ aim is to provide a stimulus for discussion that allows psychotherapists-in-training and practicing psychotherapists to engage with anxiety-provoking material. The paper highlights issues commonly involved in erotic treatment situations and in the development of technical competence in handling these clinical dilemmas. These include:

1. Anxiety and shame associated with erotic and loving feelings.

2. Differentiation between erotic and loving feelings and acting out.

3. Comfort and capacity to self-supervise, to examine in consultation, and to accept those enactments by therapists and patients that advance the psychotherapeutic process.

4. Comfort and technical competence to respond to erotic feelings with a formulation that is therapeutically sound and ethical.

5. Useful therapeutic boundary management that neither abandons the clinical frame and professional roles nor restricts and stunts the therapeutic process or abandons the patient.

The brief discussions that follow each case section are meant to highlight and examine some of the central issues. While we do not explore the meaning of Chris, the patient in the case, being presented without a stated gender, the assumptions each reader makes about Chris with respect to his/her gender, and the implications of such assumptions, should be considered. 

Curing Chris: Part I

You are a psychotherapist with a private practice in an upscale suburb. For the past seven months you have been treating a single, white patient by the name of Chris whose self-description includes “practicing Christian.” Chris is a high school science teacher who came to you complaining that a mild chronic depression has been exacerbated by the sudden death of a sibling in a car crash 11 months earlier.  Chris presented as having trouble getting to work on time, concentrating while teaching and in meetings, keeping social engagements, and keeping current with financial obligations.  Within six weeks of starting therapy, Chris also began to explore great sadness and overwhelming feelings of guilt at not having been able to protect this favorite younger sibling from an untimely death.

About two months ago, during a period in which you felt good progress was being made, Chris began to talk about problems with intimacy and sustaining personal relationships. At 31, visibly embarrassed and uncomfortable, Chris admitted to still being a virgin. This came as a surprise to you for a number of reasons, not the least of which was that it introduced a significant and hitherto unexplored element into the therapy. On reflection, you realize you had taken for granted that Chris, who is attractive and consistently well dressed and groomed, had an active personal life.

"I go out with someone a few times,"  Chris told you, while looking at the floor. "Then they expect, you know, well, you know. I was raised to believe that it's a sin outside of marriage."

As you and Chris begin to explore the issue, Chris reports avoiding all forms of physical contact with even casual friends, fearing that hand holding or a simple pat on the back could lead to demands or expectations for more extensive intimacies.

"I won't know what to do," Chris blurted out at the end of a session three weeks ago. "I'll totally flub it and look like a fool. If I could be intimate just once with someone who didn't judge me, someone who could show me how, maybe I could lead a normal life.  You're the only one who can help me."

For the past several weeks, Chris’s behavior and manner of dress have seemed increasingly sexually provocative. During your last two or three sessions, an ever more anxious Chris has described erotic dreams and feelings about you in some fairly explicit detail.

A week ago, after Chris left your office, on your waiting room table you found a small flowering plant and a card addressed to you. The card read, "You are so wonderful— the most important person in my life. You have helped me so much. I will always love you. Chris." Since that time, you have found yourself, while seeing other patients and at night, fantasizing about intimacies with Chris.

In therapy, Chris has continued to state that perhaps being intimate with someone trustworthy and knowledgeable might finally help to break through the fears. Chris’s last words on leaving your office just minutes ago were delivered in a hurt and angry tone.

"If you really cared about me," Chris demanded, "you would help me."

Questions for Consideration

1. How do you understand Chris’s difficulties?

2. How do you understand Chris’s feelings and fantasies for you—and your feelings and fantasies towards Chris?

3. What do Chris’s thoughts and feelings tell you about Chris’s:

            a. self-image, self-esteem, and sense of self?

            b. wishes and fears for the therapeutic relationship?

            c. degree of grief, anxiety, and depression?

            d. strengths and capacities for interpersonal relationships?

            e. conflicts, developmental deficits or delays with regard to interpersonal relationships?

            f. identification, tolerance, and mastery of intense affective states?

4. How does Chris seem to understand the role of a therapeutic relationship in addressing personal problems?

5. What aspects of Chris’s story stand out for you as being particularly significant?

6. What are your reactions and feelings to those aspects of Chris’s story? Why?

Discussion 1: Transference

Chris’s vignette illustrates a number of features common to sexualized treatment. Sexual excitement and love in the transference often defend against more painful affects such as loss, mourning, hostility, and/or contempt (Adrian, 1996; Bridges, 1994; Gabbard, 1994b; Gabbard, 1996; Gorkin, 1985; Kernberg, 1994; Pope & Bouhoutsos, 1986; Pope, Sonne & Holroyd, 1993). Chris presents for therapy with a depression secondary to the devastating loss of a beloved younger sibling. In crisis, grief-stricken, guilty, and lonely, Chris is vulnerable in a way that can be expected to result in the intensification of a sense of neediness, emotional hunger, wish for comfort, and relief.

The death of a loved one is an overwhelming stressor for individuals with well-established and intact intimate and social supports. In this case, sexualized transference likely signals a defensive effort to protect against the experience of grief and loss for the patient. It is possible that the painful mourning process is more than Chris can bear. Chris appears to avoid it through the transformation of those affects into sexual wishes and fantasies for the therapist.

Chris’s sense of loss and grief may be exacerbated by a long-standing sense of isolation and interpersonal impoverishment. The grief is further denied and complicated by Chris’s issues with low self-esteem, sexual inhibition, sense of shame around vulnerabilities, and disavowed desires to be touched. Chris’s religious beliefs may defend and serve as further distractions from the nature and degree of pain and developmental issues. The interpretation and application of religion, while genuinely held, may intersect with fears and developmental learning edges.

The phenomenon of sexualized transference often is accompanied by powerful rescue fantasies that may generate reciprocal fantasies in the therapist (Davies, 1994; Ehrenberg, 1992; Gabbard, 1996; Kernberg, 1994; Maroda, 1991; Pope, Sonne & Holroyd, 1993). As Chris becomes attached and begins to recount and relive relational difficulties, a mood of intensity, intimacy, and deep longing for the therapist develops. Chris idealizes the therapist. The erotic transference is complete with graphic and perhaps compelling descriptions of sexual fantasies, an expressed desire for the therapist, and almost pleading overtures for help. Chris imagines the therapist to be "perfect," a sexually experienced, knowledgeable, accepting sexual mentor, and the only person who can teach, love, and lead Chris out of a life of sexual inhibition and profound loneliness. The sense of urgency, desperation, vulnerability, and powerful wish for someone to cure Chris are evident.

Contempt and hostility are often components of an undercurrent in eroticized transference and countertransference. This is evident in Chris’s tenacious insistence that the therapist help contain sexualized aggression (Davies, 1994; Ehrenberg, 1992; Gabbard, 1996; Kernberg, 1994; Maroda, 1991; Pope, Sonne & Holroyd, 1993). The profound sense of deficit, a willingness to relinquish personal power and responsibility, and the insistence that someone fix her/him speak to childhood issues. A reworking and attempt to undo or master childhood traumas or frustration is evident in the demand to be cured (Adrian, 1996; Bridges, 1994; Gabbard, 1994b; Gabbard, 1996; Kernberg, 1994; Maroda, 1991). The sense of profound and unbearable grief around childhood issues, as well as the loss of a sibling, activate Chris’s well-established patterns of avoiding grief.

Chris appears to wish for the therapist to become the love object in her/his life and seems to long for the professional roles and boundaries to be abandoned and transformed into a personal relationship. While articulation of Chris’s wishes is important, it is crucial that the therapist understand these issues in a wish/fear paradigm, i.e., Chris also wishes for the therapist to protect the treatment and address the grief and developmental needs.

Sexual feelings often communicate nonsexual needs and wishes (Benayah & Stern, 1994; Bridges, 1994; Gabbard, 1995; Gabbard & Lester, 1995; Gorkin, 1985; Kohut, 1984). These features are prominent in Chris’s case as well. A patient's wish to be nurtured and admired in a sustaining self-object relationship may be expressed in sexual terms. Patients may be lonely, not yet capable of developing intimate relationships outside of treatment, and very conflicted about being cared for and loved.  Such developmental issues and conflicts may be expressed by demanding to have more of the therapist as a substitute for other relationships (Bridges, 1994; Gabbard, 1994b; Gabbard, 1996; Gabbard & Lester, 1995; Maroda, 1991; Schoener, Milgrom, Gonsiorek et al, 1989; Strasburger, Jorgenson & Sutherland, 1992). Chris’s desperation comes about in part due to a lack of belief in his/her capacity to acquire these experiences, self-attributes, or confidence without help. The intensity of these wishes—and inevitable frustration—is manifested in anger, humiliation, and a sense of injury when disappointed by the therapist.

A patient's experiences of sexual feelings and behaviors represent and communicate a wide range of affective experiences, developmental difficulties, interpersonal, and intrapsychic conflicts and needs. Sexuality may be a symbol, distraction, or disguise for other affects and phenomena, including a need for nurturing, admiration, or soothing; avoidance of intimacy; denial of dependency or passivity; reenactment of traumatic object relations; defense against hostility or contempt; or denial of grief, loss, and/or mourning (Benayah & Stern, 1994; Bridges, 1994; Davies, 1994; Ehrenberg, 1992; Gabbard, 1994b; Gabbard, 1995; Gabbard, 1996; Gabbard & Lester, 1995; Gorkin, 1985; Kernberg, 1994; Kohut, 1984; Maroda, 1991; Pope, Sonne & Holroyd, 1993; Tansey, 1994; Tansey & Burke, 1992; Winnicott, 1949; Winnicott, 1965).

Discussion 1: Countertransference

Although recent educational efforts, professional discourse, and psychiatric literature have made public and private acknowledgment and discussion of the sexual aspects of treatment more possible and acceptable, for many therapists such countertransferential feelings are often accompanied by anxiety, shame, humiliation, and in extreme cases "erotic horror" (Adrian, 1996; Bridges, 1994; Bridges, 1995; Davies, 1994; Gabbard, 1994b; Gabbard, 1996; Gabbard & Lester, 1995; Pope & Bouhoutsos, 1986; Pope, Sonne & Holroyd, 1993; Pope & Tabachnick, 1993; Rodolfa, Kitzow, Vohra & Wilson, 1990; Schoener, Milgrom, Gonsiorek, et al, 1989; Strasburger, Jorgenson & Sutherland, 1992; Tansey & Burke, 1992).

While we have little descriptive information about the therapist's feelings and details of the sexual fantasies in Chris’s case, we may offer some suggestive hypotheses based on the limited data provided, as well as on common features of erotic countertransference. When a patient's erotic fantasies and wishes are conscious and directed at the therapist, it is not unusual for the therapist to experience sexual feelings about the patient in fantasies or dreams (Adrian, 1996; Benayah & Stern, 1994; Bridges, 1994; Davies, 1994; Ehrenberg, 1992; Gabbard, 1994b; Gabbard, 1995; Gabbard, 1996; Gabbard & Lester, 1995; Gorkin, 1985; Kernberg, 1994; Maroda, 1991; Pope & Bouhoutsos, 1986; Pope, Sonne & Holroyd, 1993; Pope & Tabachnick, 1993; Schoener, Milgrom, Gonsiorek, et al, 1989; Strasburger, Jorgenson & Sutherland, 1992; Tansey, 1994; Tansey & Burke, 1992). The erotic countertransference may be intense, compelling, and deeply unsettling for the therapist. Gabbard (1994a) notes that therapists may feel "swept off their feet by erotic longings"  (p. 1100). It is not uncommon for a therapist who begins to experience sexualized countertransference to also feel a sense of psychic urgency which may result in avoidance, denial, or limit-setting as a defensive maneuver against feeling overpowered by unwelcome and unacceptable affects. Furthermore, feelings of shame, humiliation, and overexposure may result in professional isolation and secrecy that distorts the transference and countertransference and creates more difficulties for the therapeutic process (Adrian, 1996; Bridges, 1994; Pope, Sonne & Holroyd, 1993; Tansey, 1994), Identification and acknowledgment of these feelings are fundamental and crucial to psychodynamic understanding and competent clinical management (Benayah & Stern, 1994; Davies, 1994; Ehrenberg, 1992; Gabbard, 1989; Gabbard, 1994b; Gabbard, 1994ba; Gabbard, 1995;  Gabbard, 1996; Gorkin, 1985; Kernberg, 1994; Maroda, 1991; Pope & Bouhoutsos, 1986; Pope, Sonne & Holroyd, 1993; Pope & Tabachnick, 1993; Tansey, 1994). Anxiety generated by these affects and issues indicates a need for clinical consultation.

The most important first steps are for the therapist to tolerate the development of sexual feelings toward and from the patient and become immersed in the relational experience. Erotic countertransference may provide useful clinical information about the patient's intrapsychic and interpersonal difficulties, the state of the psychotherapy, or the therapist's person. A free, full internal fantasy and romantic or sexual narrative may inform clinical hypothesis formation and protect against behavioral enactments. It allows the therapist to experiment with multiple lines of inquiry and entertain the many narratives which are necessary for arriving at a well thought out formulation (Bridges, 1994; Davies, 1994; Gabbard, 1994b; Gabbard, 1996; Gabbard & Lester, 1995; Kernberg, 1994;  Maroda, 1991; Tansey, 1994).

Erotic countertransference may also signal intense, unconscious feelings of identification, a shared sense of longing, and a validation and echoing of one's experience. A therapist’s state of sexual arousal may serve to protect the therapist from feelings of contempt or anger at a patient’s intense neediness and demands for relief. While the therapist in the presented case, for example, appears to feel powerless in the face of Chris’s grief and developmental difficulties, the therapist also may be aroused and excited by the idealization and the extent of Chris’s vulnerabilities. As a result, the therapist may err by joining Chris in the fantasy of being a special, loving healer.

In summary, erotic countertransference alerts one to a complex interaction between therapist and patient. Gabbard (1994a) conceptualizes intense erotic feelings in treatments as displaced feeling states composed of a "mixture of a real relationship and remnants from past object relationships"(p.172). Sexual feelings are thus symbols that have multiple and varied meanings: Useful formulations are not gender-specific (Benayah & Stern, 1994; Bridges, 1994; Davies, 1994; Ehrenberg, 1992; Gabbard, 1994b; Gabbard, 1995; Gabbard, 1996; Gabbard & Lester, 1995; Gorkin, 1985; Kernberg, 1994; Maroda, 1991; Pope & Bouhoutsos, 1986; Pope, Sonne & Holroyd, 1993; Pope & Tabachnick, 1993; Schoener, Milgrom, Gonsiorek et al, 1989; Strasburger, Jorgenson & Sutherland, 1992; Tansey, 1994; Tansey & Burke, 1992).

Curing Chris: Part II

Concerned about the direction your work with Chris seems to be taking, you decide to seek supervision from Dr. Noetal from whom you have been receiving supervision for several years. Dr. Noetal has impressive credentials, has published several articles on countertransference in juried journals, and is the senior psychotherapist at the student health services at a local college.

You are acutely aware of your anxiety and discomfort aroused by Chris’s presentation and feelings. While, as a therapist, you expect to have feelings and reactions to psychotherapy patients, the intensity of your feelings for Chris, and the intrusion of day and night fantasies, have left you with a sense of silent shame, guilt, and embarrassment. Although you have wanted to explore your personal experiences in this treatment relationship, you have avoided discussing your feelings about Chris and Chris’s treatment in your peer support group.

You are unclear about how your various feelings relate to the psychotherapy process and whether these feelings are about you, about Chris, or both. Additionally, you feel that the intensity of Chris’s attachment to you, the sexual feelings, and the gift giving are all problematic. Your hope is that by presenting Chris’s case to Dr. Noetal you will be better able to understand and manage the range of thoughts and feelings in yourself and your patient.

At your meeting you describe, as factually as possible, what you know of Chris’s personal history, and you describe your work with Chris to date. Dr. Noetal asks you several questions including how you understand Chris’s difficulties and about the aspects of Chris’s story that stand out for you as being particularly significant. Since you have given these questions considerable thought, you answer them in detail.

"What, in your behavior," Dr. Noetal then asks, "do you think has elicited this behavior in Chris?

“Generally,” Dr. Noetal continues, “when a patient becomes seductive in this way, it is due to some body language or other action or words from the therapist. I would be very careful here, detailing everything you do from now on. This patient sounds like a loose canon—and you are clearly mishandling the transference. If you're not careful, this is the kind of patient who will get angry and sue. You're being set up here.  After all, if lack of a sex life was a real issue for this patient, it would have come out long before now."

"My advice," Dr. Noetal tells you, "is to move the patient away from discussions of sexuality. This is an arena that can only get you into trouble. Instead, explore issues of social isolation that relate to the patient's personality disorder and talk about the meaning of the loss of the sibling.  Also, I think this patient may be using religion as a defense, so you'll have to find out what that's all about. Besides, real practicing Christians don't talk the way Chris is talking to you."

Dr. Noetal concludes the interview with the following instruction: “If you can't get this patient to stop talking about sex, then I think you ought to terminate immediately and refer."

You leave Dr. Noetal's office wondering how to proceed.

Questions for Consideration

1.  What aspects of Dr. Noetal's assessment and advice stand out for you as particularly significant? Why? What aspects were helpful, and what aspects were not helpful?

2. If you were the supervisor in this case, how would you have handled this consultation? What are the specific issues you would like to see the supervisee consider? How would you conceptualize the dilemmas in this psychotherapy and the therapeutic relationship?

3. How will you proceed?

Discussion 2

Chris’s therapist uses good clinical judgment in seeking consultation. A knowledgeable supervisor/consultant should be able to directly and simply normalize the therapist’s feelings of shame, phobic dread, and self-consciousness associated with sexual feelings in clinical practice and establish a milieu of safety and openness. Ideally, the supervisor assumes a matter-of-fact and self-revelatory stance with regard to these clinical issues and consciously uses her/himself as a demonstration model (Allen, Szollos & Williams, 1986; Alonso, 1985; Bridges, 1995; Gabbard & Lester, 1995; Hoffman, 1990; Hutt, Scott & King, 1983; Jacobs, David & Meyer, 1995).  When this happens, there is a high likelihood that the therapist will recreate with her/his patient the tone, stance, and attitude of the supervisor around these issues (Alonso, 1985; Bridges, 1995; Hoffman, 1990; Hutt, Scott & King, 1983; Jacobs, David & Meyer, 1995).

However, when supervisors are startled with intense affect and complicated material, it often challenges their capacity to bear and process affect in a complex and meaningful manner. If intolerant of intense affect, inexperienced, or inadequately prepared to formulate a case, a supervisor might resort to defensive maneuvers including retreating to a one-person model of therapy and shaming or blaming the therapist or the patient (Allen, Szollos & Williams, 1986; Bridges, 1995; Davies, 1994; Hutt, Scott & King, 1983; Jacobs, David & Meyer, 1995). In the authors' experience, these types of supervisory consultations are still commonly reported by therapists and therapists-in-training. Unfortunately, they reinforce the notion that sexual feelings and dilemmas are best managed without consultation. This is certainly the scenario that Dr. Noetal presents.

After a brief discussion of Chris’s history and treatment, Dr. Noetal launches into an unfortunate examination of the therapist's possible contributions to the eroticized treatment. Dr. Noetal appears to be blaming both the therapist for the patient's sexual feelings and the patient for introducing intense affect and vulnerabilities. Dr. Noetal's insensitive line of inquiry, and focusing on the therapist's behavior and pejorative judgments of the patient, will most likely feel intrusive, pathologizing, and injurious, and most likely will prompt defensiveness in the therapist. It's hard to imagine the therapist in this case taking the risk of exposing more of her/himself and the intimate details of the treatment process in the impersonal climate that Dr. Noetal has set.

While Dr. Noetal has accurately perceived Chris’s hostility and neediness, there is no acknowledgment that Chris’s sexual and other intense feelings are "real." Dr. Noetal's sense that the therapist needs to be afraid of the patient or defensively anticipate litigation is also not helpful. Dr. Noetal's judgmental assessment of Chris’s religious beliefs additionally misses an opportunity to use spirituality as a symbolic communication around issues with desire, dread, sensuality, touch, terror in connection, etc. By using religious beliefs as a vehicle for exploration and discussion, Chris may be able to deeply discuss, in displacement, wishes, fears, and conflicts that feel too shameful to own.

Dr. Noetal's recommendation that the therapist terminate and refer Chris to another therapist if sexual feelings remain a focus of treatment is also not helpful. This comment leaves the therapist feeling as if the treatment and therapeutic relationship are "bad" or unethical. While the therapist needs some supervisory assistance on how to discuss gift giving and boundary maintenance, and to refocus the patient on developmental relational issues, Chris is talking about the therapeutic work that needs to be done. The therapist has tolerated admirably the emergence of intense sexual feelings in the patient and self and might well be congratulated by a supervisor.

Curing Chris: Part 3

Because you are still concerned about your situation with Chris, you decide to seek a second consultation—this time with Dr. Weisberg. You arrive at Dr. Weisberg’s at the exact time of your appointment and find the door to his office open. As you begin to sit down in the adjacent waiting room, Dr. Weisberg appears at the door, invites you in and asks you to take a seat, gesturing in the direction of a nearby chair.

You begin cautiously by detailing Chris’s history and presenting complaints. Dr. Weisberg asks you several questions along the way, which you answer in a straight-forward manner.

“This sounds like an interesting client,” Dr. Weisberg says. “It sounds like you have a solid grasp of the issues involved in this treatment. What specifically then,” he continues, “would you like to get out of this consult?”

You inhale slightly and begin to describe Chris’s gift-giving, some of Chris’s problems with sexuality, and finally, Chris’s stated sexual fantasies about you. This time, unlike your session with Dr. Noetal, you omit mentioning anything about your own sexualized countertransference. When you have finished, Dr. Weisberg tells you the following story:

“When I first started practicing, I think it was actually during my residency, I had a patient who began quite early on to describe sexual fantasies about me. Some of them were pretty graphic and detailed. In a very short time, I found myself having similar fantasies about this patient even though, when I actually thought about it, I realized the patient was not especially attractive to me. I was quite frightened at the time by the patient’s seeming idealization of me and of my own feelings as well, but I realize now that information generated both by transference and my own countertransference can be very useful.

“Your coming to me about this case tells me that you’re very thoughtful about the welfare of your patients. I’m fully aware of how difficult it can be to confront and deal with material of this kind.”

With somewhat less trepidation, you describe your concerns with the sexualized countertransference.

“When I had my first experiences with sexualized countertransference,” Dr. Weisberg tells you, “I kept it a secret for fear of being badly judged. That actually made things worse, and I consider myself lucky that at least I knew enough not to act out the countertransference. Now I realize that pretty much all of us in this business experience both sexualized transference and countertransference at some time or other, and usually more than once. Anyone who claims they never have is probably in denial.”

“What I’d like to do,” Dr. Weisberg tells you, “is set up one or two more appointments in which we can explore the symbolic meanings of the sexual transference and countertransference, and explore ways that we can use that information for formulating a useful treatment approach.”

After you have agreed to the additional supervisory sessions, Dr. Weisberg outlines some of the questions he thinks would be useful in moving ahead, including whether the feelings inherent in the transference and countertransference might be helpful in informing you about your own and your patient’s developmental deficits, developmental gains, needs to boost self-esteem, and wishes for admiration. He suggests you also consider the degree to which the feelings might be defenses against disappointment, hate, grief, and even expressions of rage.

Once this agenda has been established, you set up two additional appointments and leave, feeling at last less burdened and more hopeful that you will be able to succeed in Curing Chris.

Discussion 3

Dr. Weisberg quickly establishes a climate of safety and openness within which it is possible for the supervisee to confront difficult material. His next steps are to begin to introduce a philosophy and clinical framework for analyzing erotic transference and countertransference. The useful clinical consultation focuses on acknowledging the feelings, understanding the multiple and varied interpersonal and intrapsychic meanings in the treatment dyad and context, and deciding how best to use the information. This supervisory stance encourages self-reflection and the formation of creative hypotheses. The therapist is freed up to focus on symbolic meaning and the development of complex, compassionate psychodynamic formulations that advance the therapeutic process (Alonso, 1985; Bridges, 1995; Gabbard, 1994b; Gabbard, 1996; Jacobs, David & Meyer, 1995; Pope, Sonne & Holroyd, 1993).

The supervisor models the exploration of erotic feelings from both the therapist's and patient's perspectives with the understanding that these feelings signal information about developmental issues and relational experiences.

Dr. Weisberg has laid out some of the questions that he and his supervisee will need to explore. Bridges (1998) formulates additional questions a supervisor might pose, including:

1. What developmental issues and attendant affects are being longed for, repeated, or defended against with these feelings?

2. Do the feelings defend against more intolerable affects, for example, sadism, terror around others, or denial of vulnerability/dependency?

3. Do the feelings represent an unconscious effort to maintain positive feelings, a wish to be loved, to be cherished, or to love another?

4. Do the feelings signal a reenactment of an earlier traumatic relationship or experience of exploitation with a trusted other?

After the supervisor has provided the therapist with a conceptual framework and assisted with the development of multiple hypotheses for exploration with the patient, the therapist may more comfortably focus on the meaning and use of the therapist's self. In intense transference-countertransference states, the therapist often struggles with multiple points of identification and shared experience, including whether the patient's sexual attraction and desire is pleasurable for the therapist, resulting in a wish to have it continue (Adrian, 1996; Bridges, 1994; Davies, 1994; Gabbard, 1994b; Maroda, 1991).

In addition, supervisor and supervisee will explore the possibly burdensome and relentless aspects of the patient’s idealization of the therapist. On occasion, a therapist who feels besieged by a patient's repeated requests for special connections or extending the treatment boundaries gives in and grants unusual and often unhelpful requests. Such behavior by a therapist may be a manifestation of contempt or hostility that is unacknowledged (Bridges, 1994; Davies, 1994; Gabbard, 1996; Gabbard & Lester, 1995; Kernberg, 1994).

Dr. Weisberg will also assist in helping the therapist to directly and sensitively address and explore with Chris the sexual feelings and love, with a focus on identifying the underlying nonsexual needs, wishes, and beliefs (Adrian, 1996; Bridges, 1994; Davies, 1994; Kernberg, 1994; Pope, Sonne & Holroyd, 1993). Additional issues to be explored with Chris include the profound sense of loneliness, the relationship to and loss of the sibling, personal history and mythology about undesirability and being unlovable, capacity to acknowledge feelings and self-comfort, and ideas and attitudes about how people change.

The therapist would do well to maintain a dual focus on Chris’s internal intrapsychic world and external world. While Chris is feeling and exploring self and the relationship to the therapist, it is also important to remain attuned to self-initiatives, pauses, and developments in the outside-of-therapy world of relationships and activities. Chris needs treatment but also a richer and more sustaining life.

Conclusions

Virtually every therapeutic dyad sooner or later confronts one or more of the erotic transference/countertransference and resultant treatment issues presented in Curing Chris. Despite this, they are among the least discussed in clinical training. Because most supervisors/consultants also lack training in this area, it is natural that many pass on to their supervisees the anxious and defensive attitudes illustrated by Dr. Noetal. While there are no absolute explanations for understanding the complex dynamics of erotic transference/countertransference, integrating specialized core curricula can do much to provide both a framework for thinking about treatment issues and a safe milieu within which to discuss the myriad associated emotions.

A therapist's capacities to identify, tolerate, contain, and formulate erotic feeling states are crucial to competent handling. One useful approach views the therapist as a full participant who brings wishes, needs, and unresolved object relations into the therapeutic relationships. A relational model of psychotherapy that understands the value of full participation by both parties is also helpful. Reenactments of earlier relational dilemmas for both therapist and patient provide pathways to new personal growth, development, and mastery (Bridges, 1994; Davies, 1994; Gabbard, 1994b; Kernberg, 1994; Maroda, 1991; Tansey, 1994). In this approach, therapists consciously try to identify subtle shifts in the transference and countertransference as sensitive cues to inform and deepen the work. A therapist's self-scrutiny and careful attention to the unique factors in each treatment dyad and process lead to the development of a useful formulation and intervention (Adrian, 1996; Bridges, 1994; Davies, 1994;  Gabbard, 1994b; Kernberg, 1994; Maroda, 1991; Tansey, 1994).

The danger of destructive behavioral enactments is real. Therapists most at risk are those under great personal or professional stress or those who use patients in a narcissistic, self-serving manner (Blackshaw & Patterson, 1992; Gabbard, 1989; Gabbard, 1994b; Pope & Bouhoutsos, 1986;  Schoener, Milgrom, Gonsiorek et al, 1989; Strasburger, Jorgenson & Sutherland, 1992).

With experience and practice, therapists will develop and integrate a model of conceptualization that fits their personal and clinical style. Supervisors play an important role in assisting therapists with this professional developmental task.

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