Andrea Celenza on Sexual Boundary Violations - The Reluctant Psychoanalyst Thinks about Psychotherapy

Writing about psychoanalysis is usually fun.  I like blogging.  The time goes quickly, but I feel like I have accomplished something during those flying moments.  Writing about Psychoanalytic sins has not been fun.  It has taken much longer than usual to write this blog, and it is clunky - I put off writing it (OK, it's also the end of the school year and there hasn't been time for it) and now some of the details have become foggy.  At the same time, I have been bedeviled by the theme and I have had trouble articulating my bedevilment.  Instead of writing about the stuff that is troubling me, I have found myself dutifully reporting stuff - facts and impressions - and not talking about other stuff - shadowy disturbing stuff - the underside of the world of psychoanalysis and psychotherapy more generally.  So please, forgive me ahead of time that the following is not as cogent as I would like it to be.  And please know that I will try to write about the shadows, as far as I am able, here, but also across time, as I am able to...

My local institute invited Andrea Celenza to present to us.  She comes to us from Boston where, she ruefully noted, there has been a spate of high profile sexual boundary crossings by revered psychoanalysts.  She, herself, has been working with therapists and analysts who have crossed sexual boundaries since a referral early in her career, when she would have taken anyone on. A referral came to her from someone - I think a respected mentor - who thought she could help a therapist who had lost his license after having had sex with his patient.  This turned into a specialty area of practice for her and she has written a book about treating therapists who have had sex with their patients.  She has gone on from there to write about the erotic in the psychoanalytic encounter - and most of the weekend was spent discussing this much more interesting (and oddly related) topic, but I will focus on the earlier work, with which she began the weekend.

First a little background.  Sex between psychotherapists and their patients has been, for some time, the third rail of therapeutic practice.  It is the cardinal sin:  malpractice insurance won't cover it - and it is the most frequent malpractice complaint.  Every therapist (now - see an example of the damage caused when this was not the case with Anne Sexton) knows it is wrong: there is considerable empirical evidence of the negative consequences and all training programs warn against it, and yet it still occurs with some frequency.  Dr. Celenza cited a study that asked therapists - once they had been assured that their responses would be anonymous - if they had ever had sex with a client.  This is a place where I am a little fuzzy about what she said, so I did a brief search, and the studies cite a wide range of statistics, but I think she said that, overall, about 6% of surveyed therapists acknowledged that they had engaged in a sexual relationship with one or more of their clients, but there is a huge sex difference.  Only about 2% of females stated they had done this, while 10-15% (or maybe more - perhaps as high as 20%?) of males did .

Even more background:  At the dawn of psychoanalysis and psychotherapy, the problems with having sex with clients were not so clearly articulated.  Freud was strongly opposed to crossing sexual boundaries, but other analysts, including Jung, maintained there could be therapeutic outcomes and engaged in sexual activity with their patients.  When I was in graduate school, the ethical principles of the American Psychological Association included the caveat that it was OK to have sex with patients once the treatment ended.  The scuttlebutt I heard at the time was that this caveat was included in no small measure because there were members of the ethics committee who were married to their former patients and saw no harm in this.  Since then, the ethical principles have been amended to clarify that sexual contact with a patient at any time is considered unethical.

I have wandered from the focus of this blog, however.  Dr. Celenza began her interactions with us focusing on the treatment of therapists who, despite knowing that sexual contact with their patients has the potential to ruin their own careers and to harm the people whom they are presumably there to help, engage in that very behavior anyway.  Glen Gabbard, another analyst who writes about this topic, divides the offenders into two groups:  Sharks and Love Sick Therapists.  Fortunately sharks are, by far, the minority of offenders.  Their interest is in having sex with patients.  They are usually frequent offenders and show little or no true remorse.  These are not good candidates for therapy - they need to have their access to potential victims curtailed - they need to have their licenses removed and - here I hesitate - be sequestered. Should they be jailed?  Let's leave that as a question for a moment.  These sharks though are also, weirdly, frequently slippery enough to avoid prosecution.  It is the love sick therapist, someone who general offends once, who is more likely to be caught and prosecuted and have his license removed.

The profile of the love sick therapist is a scary one - and here is one of the shadows - it sounds a lot like me.  These are generally individuals who have been compassionate therapists.  They are more likely than others to have served on ethical committees in their careers (Full disclosure: I served on the ethical committee of my state psychological association early in my career).  They are generally mid to late career therapists who are facing difficulties in their extra therapeutic lives.  They may have marital difficulties, or may feel some sense of career failure, perhaps failing to achieve an expected milestone (OK, I wax and wane in this department - as I suppose we all do - but interestingly as I have been struggling with writing this blog, I have focused more on my failures than I usually do).  In the context of this personal configuration, they begin to engage in uncharacteristic interactions that involve boundary crossings with their patients - perhaps meeting with them at a coffee shop, but also beginning to talk with them about their own lives, confiding in them rather than the other way around.  This becomes a slippery slope that can lead to sexual interactions (This is not a slope that I have slipped down to this point).

Dr. Celenza started the weekend with a conversation about her older work in part because our institute is one that, like many others, has been rocked by revelations of boundary crossings.  We are currently in somewhat of a lull - most of the revelations feel like old news - until we start talking about them and then they emerge again - fresh and painful.  So we talked about the experience of the ways in which the boundary crossings had disturbed us.  Then we talked about treating therapists who have crossed sexual boundaries.  The conversation became heated when Dr. Celenza proposed that those individuals who can be treated - essentially the love sick therapists - can and even should be rehabilitated - that they can become better therapists (better than they were themselves before offending and perhaps better than others, on average) in the wake of having crossed boundaries and having been treated for that.  This is a bold statement.  We talked a bit about it, and I have puzzled over it since.

All psychoanalysts are required to engage in their own analyses.  Many therapists engage in an analysis or some other kind of treatment as well as part of getting to know what it is like on the other side of the therapeutic relationship.  For analysts, the required treatment is called a training analysis, and while the experience of conducting one is referred to as being similar to "personal" analyses, an additional resistance (by which I mean warding off the impact of the treatment) to the training analysis (along with all the usual suspects) is that we say, "This is not something that I really need.  It is a requirement of my training."  When a person is remanded to treatment by a state licensing board; when this is a result of their having touched the third rail - of having engaged in behavior that has harmed a person that they have been paid by to help; when their personal relationships have been strained or broken by the revelation of their behavior, when the financial consequences have been huge - it is harder to justify the treatment as simply something that I need as an educational requirement.  There is a very real problem that needs to be addressed.

The treatment also gratifies a need that the boundary violation exposed.  The therapist, no matter how much he (and occasionally she) may try to justify it, is doing something for him or herself.  He is acting, not out of altruism, or even out of mercenary professionalism, but out of selfish need.  And this need - and it may sound weird for an analyst to say this - is not primarily a need for sex - but a need for nurturance, for succorance, for being cared for.  Freud, who never was analyzed by someone else, trusted that the training analysis would help the future analyst resolve conflicts in such a way that he or she would not need to obtain gratification in the treatment.  Our conception of psychological need is much more fluid and dynamic than his was.

I think it is the case, and this is part of the shadowy aspects of all this, that the presence of the analysis or therapy has a half life.  One of the reasons that I think that we meet as frequently as we do (in orthodox analysis 4 or 5 times - sometimes 6 times a week) is that this helps with the half life - for the analyst and the analysand.  We are still connected with the material from yesterday while dealing with the material that has occurred since then.  Across the years of an analysis, we build up a bank of a certain kind of relationship - a relationship in which - when things go as they should - we feel heard and understood.  This gets, in analytic terms, "internalized".  We have a more or less constant sense of the presence of a relatively benign caring other - one who has access to our thoughts and works with us to understand them, so we feel comfortable with our thoughts and work to try to understand them ourselves - to self analyze - and further there is a sense that what we have to say makes sense and this gives us - or at least me - the courage to articulate those thoughts, at first to another, but the internalization means that we continue to articulate them to ourselves - we self analyze, meaning that we don't deep six those thoughts but let them roll around in our minds to see what purchase they find.

But this sense of the available other, this bank of empathic connection, has its own half life.  And while we may end an analysis when we are relatively "full", a few years or decades later we may have lost some of the sense of centeredness, of certainty - a certainty that, at its worst can be arrogance, but at its best can help us hold to difficult positions long enough to see if they are valid - whether in our roles as analysts or in other settings.  So one way of thinking about what happens that leads us to engage in boundary crossings - and here I may be talking about my shadowy self - is that we lose track of the sense of being heard and understood and start to look for that in the wrong places - in the minds - and not soon after the bodies - of our analysands.  It is a weird world we live in - and here I think I am being a bit defensive - where we spend all day relating to people and yet can feel terribly isolated.  Our private lives can feel absolutely off limits - which they should be in the therapeutic hour - but the sense of isolation can generalize beyond the therapeutic hour and feel absolute - that while others need us, it is not OK for us to need others.

Dr. Celenza did not talk about these parts of the experience, and to a certain extent I am imagining them.  What she talked about was the transformative power of psychotherapy and the ways in which former therapists respond to being heard - or heard again.  And how they engage in the difficult work - perhaps work not done before - perhaps work covering ground that feels well tilled until the plow comes again and it, like our experience of the upheaval in our institutes, emerges wet and new and fertile, alive again with the memories and dynamics that brought us to therapy to begin with.  And we work that soil because we now know how fertile it can be - that it can bring forth good fruit or, if not tended, support weeds.  OK, speaking of weeds, I think I got lost in them with the metaphor, but I'm hoping the point comes across.

But our group was not particularly responsive to Dr. Celenza's message.  There were those among us who rejected this notion of rehabilitating those who have had sex with their patients out of hand.  The position of the nay sayers was that, without the threat of expulsion, people will sleep with their patients.  If they know they will get a slap on the wrist, then get treatment, then get back in the ring, they will do it in a heart beat.  And this is part of the shadow, too - that my fellow analysts have as little trust in each other - in me - that they don't believe anything short of expulsion will keep me in line.  Worse, they propose that the offenders are not to be trusted in what they say.  That they will claim to be "Love sick therapists" when they are, in fact, sharks.  They know what we want to hear and will produce it, but real remorse is beyond them - that is, that we are not well intentioned but flawed humans engaging in a dangerous but potentially life-giving activity, but cunning animals holding our dangerous urges in place with the slenderest of leashes.

Which brings me to a shadow place.  I remember an incident, I won't go into details, when I really did harm someone.  I was 20 years old or so - you should know that I am a person who is riddled by guilt and I am constantly apologizing for things I have done and things I have left undone (OK, there is a religious basis here), but when I was 20 years old or so, I truly injured someone and felt, I think for the first time, true remorse.  I felt bad.  And I found that fascinating.  I recall observing myself and being aware that this process was taking place - I didn't feel badly about what I had done - I felt bad.  I felt something like sorrow, something like pain, something like being heartsick - whatever it may have felt like, centrally is just felt bad - viscerally.

I have never treated a therapist who has crossed sexual boundaries, but I have treated incest offenders.  This was my way in - and Dr. Celenza agreed that there are parallels here.  In successful treatments, the incest offender comes to feel bad.  They (and again there are two populations here - some are not treatable, but some are, and I am talking about the treatable ones) have always felt guilty.  They have known that what they have done is wrong, and they knew that while they were doing it, but they did it anyway.  In treatment they come to know that, no matter how they may have explained it to themselves, it was a violation of a basic trust and when they realize this, they feel remorse.

I think that this may be at the heart of why this is so difficult for me to write about - we are entrusted, as parents - as friends - as teachers and coaches - and as therapists and analysts - with a sacred vow.  To protect and help heal those who come to us for care.  Most of the time we bear this trust lightly.  It is part and parcel of the task.  We engage in it more or less effortlessly.  When we expose it; when we open it up and look at it, it is a bigger task, a more weighty responsibility than we generally recognize.

I think that my friends who would encourage us to up the ante on the punishment side are trying to impress us with that weight as a pre-emptive corrective (OK, should we imprison these offenders?  Karl Menninger talked about the crime of punishment - and there are people who, I believe, are not remorseful and won't be able to access their sense of badness - and others should be protected from them.  Locking them up is one way to do this - but I don't believe that the penitentiary will make them any more penitent than a failed treatment would.  I think we need to be clear about the intent of the punishment and, if it is to prevent the behavior - to hold up an example - I think the empirical literature states that this is not an effective way to deter the target behavior - in the offender or anyone else).  I think, though, with Dr. Celenza, that the lived experience of having harmed another, of feeling remorse, of offering appropriate reparation, and of coming to know what fragile creatures we are is ultimately the best deterrent and may forge us into becoming the therapist or analyst that we might have been.  God forbid I should ever have to walk that path to get there.


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