Welcoming the erotic into therapy

BY Paul Hitchings

Mention of the erotic in the therapeutic relationship seems to create panic in many therapists. It is relegated to a transferential event and so seemingly maintains therapist ‘innocence’! This article aims to offer a broader and friendlier conception.

The ‘erotic’ may be conceptualised as ‘embodiedness’ in relating. The term ‘embodiment’ can be defined as follows: …..embodiment really refers to a process that produces a network, woven through the fabric of our body functions and cognitions and our behaviour, connecting us to the physical environment and synchronising us with the cognitions and behaviours of other people.

(Hauke & Kritikos, 2018).

Embodied communication occurs in the presence of mutual influence, between people in engagement. Being fully present means a sensual connection requiring more than our mind. We might be less or more engaged with one person as opposed to another. We might be working with a child, an older person, someone attractive to us, someone we are moved by or someone we struggle to connect with. What impact do the ‘real’ and ‘co-transferential’ relationships hold? A mapping of different (but not discrete) states is offered.

A Map

The erotic/embodied is conceptualised here within four quadrants. The map has two axes; a continuum from the ‘real’ to the ‘transferential’ relationship and a dimension from the ‘non-genital erotic’ to the ‘genital erotic’, which locates embodiment, including sexuality, in the therapeutic encounter. One or both members of the dyad may occupy the same quadrant, or an invitation by one member into another quadrant may describe the current dynamic.

Illustrative examples in relation to each quadrant follow the diagrammatic map. Case vignettes are given to illustrate each.

Four quadrants of ‘erotic’/‘embodied’ relating

‘Real’ & Non-Genital  Quadrant 1	‘Real’ & Genital  Quadrant 2
Transferential & Non-Genital  Quadrant 3	Transferential & Genital Quadrant 4

Quadrant 1: ‘Real’ and non-genital erotic relationship

This is the quadrant within which most therapy happens, characterised by presence of the working alliance and the real relationship.

Quadrant 1 Case Vignette:

This reflects a movement from Quadrant 3 to Quadrant 1 (Transferential/non-genital to ‘Real’/non-genital). Beginning in an engaged way in the third client session, I began wanted to close. The subsequent session was scheduled for early morning, a time when my energy level was high. Again a few minutes into the session the same sleepy state descended upon me. Reflecting on the robustness of the client, I decided to disclose my embodied experience and they responded, ‘Oh yes, I think that I don’t want people to really notice and see me’. The ‘spell’ was broken and we re-engaged with good contact. We had travelled from a transferential to a ‘real’ engagement.

Quadrant 2: ‘Real’/Genital erotic relationship

With the intimacy of the therapeutic relationship, it is normal that some element of the ‘genital erotic’ will emerge. The ‘genital erotic’ needs to be thought of as a continuum; from the quiet bodily admiration of the other, to passing sexual thoughts and along to considerable sexual desire.

The ‘erotic’ is always present and if overly minimised, it will be to the detriment of the therapeutic work. Premature closing down of the experiences of either party due to therapist anxiety can be counterproductive (Smith Pickard, 2014). If we can avoid shame based responses then we are freed to consider what such experiences might mean for us and/or the client. Such material may well need time to emerge in the relationship.

A question might be ‘From which person does the ‘genital erotic’ originate?’ Whilst it belongs in some way to both parties, the question of from whom does this primarily originates, is one that remains useful. The subsections below consider ‘Cupid’s arrows’ flying from one or other participants, although we know that the arrows can be flying in both directions!

The ‘genital erotic’ energy from the client toward the therapist.

This is common, with 73% of therapists reporting as having had the experience of clients showing sexual attraction toward them (Pope & Tabachnick, 1993). The therapist needs to be alert to what usually is the slow unfolding of the more ‘genital erotic’. Therapists need to have the courage to allow the erotic to emerge clearly. It is essential not to close up the ‘talking about’, whilst also holding the boundaries.

As there is likely to be significant meaning for the client, the therapist must bear being the object of desire (see McIlwain, 2014). Therapists need to hold themselves in the place of the “disappointing lover" (Messler Davies, 2003). A concern here is to avoid shame.

The literature is sparse on the management of a client’s attraction, and there is a gulf between knowledge, intent and actual practice. Kirby (2019) noted that therapists were aware of erotic communication from clients but ignored it. However, hoping it will go away to allow the ‘work’ to proceed should not be an option. The following vignette evidences what good practice can achieve.

Quadrant 2 Case Vignette 1:

The attractive female therapist began to notice that her male client almost always used the bathroom at the start of the therapy session. He would emerge into the room and whilst standing close to her, before settling into the chair, would be completing the buttoning of his fly. Initially, she paid no attention but this gave way after a number of sessions to unease. After supervision, she gently began to enquire about his relations with women. It emerged that they were always over-sexualised and used as his only means of making contact. The eroticised therapy dynamic could then be surfaced and talked about which led to a non-shaming discussion.

Similarly, Lotterman (2014) gives an engaging account of work with a male client who had strong sexual feelings toward her. These examples illustrate openness to the client, therapist acceptance of their own unease, sensitivity of timing and management of encouraging open discussion, whilst holding the therapeutic boundary. This is a complex dance for which there may be broad guidelines but no perfect formulae.

The ‘genital erotic’ energy from the therapist toward the client. Our sexuality manifests across a continuum from deeply felt warmth all along to full genital erotic desire. Given a sufficient number of clients seen in our practices across years, how could we not find some of them genitally erotically desirable?

In contrast to holding the stance of being the “disappointing lover”, we now need to hold the metaphorical stance of being the “disappointing lover” (Messler Davies, 2003).

Linked to our reflexive stance, we might engage with some useful self-supervision questions: ‘What might this mean about me? About them? About us? What if anything needs to be done?’ A question is whether we communicate our feelings to the client. The literature is almost univocal that we almost certainly should not:

The main task of the therapist in these circumstances is to be able to have erotic desires objectively. That is to say, the therapist should feel but contain them.

(Mann, 1997: 60)

…. Erotic fantasies should not be shared with the patient.

(Mann, 1997: 66)

Quadrant 2 Case Vignette 2: When ‘R’ entered my consulting room I was immediately taken by his looks, attractive demeanour and charming manner. I felt almost spellbound, self-conscious, simultaneously wanted to look at elements of his body and to avoid noticing those aspects. Psychologically thrown off balance, I used my supervision to talk of my desires, hesitation, guilt at being ‘caught’ and the desire to refer him on quickly. What emerged in supervision was that this was my opportunity to paradoxically accept my private genital erotic desire whilst learning not to ‘sexualise’. The tension subsided with energy being freed to do the therapeutic work. Some months later into our work, my client said, ‘I don’t easily get seen in the world, noticed yes…noticed very, very much… but seen, really seen … you have’ (with both of us in tears).

Quadrant 3: Transferential and non-genital erotic

This quadrant of the erotic is often characterised by ‘boundary crossings’ which can be situated on a continuum moving toward ‘boundary violations’. ‘Boundary crossings’ can be, “harmful, helpful or benign to the therapeutic process” (Fasasi & Olowu, 2013) whilst boundary violations almost always have a damaging outcome.

We are likely to be able to differentiate between helpful and harmful ‘boundary crossings’. However, in ‘erotic transferential’ infused relationships, we are susceptible to elements that can propel us into ‘boundary crossings’ which may be harmful. These might be at the ‘softer’ edge (e.g. regularly going a few minutes over time) to potentially unhelpful or harmful – (e.g. not challenging, keeping client in therapy beyond appropriate point).

Quadrant 3 Case Vignette:

Six sessions into the work with a likeable and confused female client in her late 20s who was in the midst of a romantic bereavement, I experienced a strong embodied parental countertransference. I wanted to give her a home – my home! I wanted to mentor her and parentally give her what she had lacked in life. Discussing my powerful countertransferential response in supervision, it became evident that what the client needed was encouragement to experience her own agency and develop ‘her own mind’. The supervisory discussion of this embodied erotic response, in a non-shaming manner prevented the work being infused with an over-caring atmosphere.

Quadrant 4: Transferential and genital erotic

There is a gradation between the ‘real/genital erotic’ (Quadrant 2) and the ‘transferential and genital erotic’ (Quadrant 4). Each are differentiated by the ability to hold a greater or lesser reflective stance. The literature in this area (e.g. Black, 2017, Sarkar, 2004, Celenza, 2010) mostly refers to overt ‘boundary violations’; however it is also worthwhile considering vicarious forms of ‘boundary violations’. Examples here include eliciting an overdetailed account of the client’s sexual life and encouragement or failure to challenge risky romantic engagements.

Quadrant 4 Case Vignette:

A young client in a weekly gay men’s therapy group complained that they had considerable anxieties in regard to their erectile ability in the arena of casual sex. The therapist offered a solution, that of learning to enjoy ‘passive’ anal sex where the erectile concern would be lessened. For the client this was not an activity that they wished for, but the therapist held to a directive stance inviting other group members to endorse the suggestion.

In supervision, the therapist recognised that he found this client sexually desirable and had the fantasy of engaging in such activity with this client. Whilst the boundary might not have been transgressed, it became clear that this was a vicarious boundary violation. This seems an example of what Celenza (2010: 62) refers to as, “finding some aspect of yourself in the patient, driven by your need … a self-other confusion”. This could also be expressed as metaphorical rape of the client!

Preventing boundary violations

Blechner (2014) lists numerous famous historical analysts who had sexual relations with their patients. Such behaviour is now seen as exploitative. It seems always damaging to the patient (Seto, 1995), to the clinician themselves and to the profession.

Attempts at an estimate of the incidence of events of sexual involvement with clients based on available literature yield a figure of 5-10% of practitioners, with female patients constituting 80% of victims (Alpert and Steinberg, 2017; Sarkar, 2004; Pope et al, 1986). Celenza (2010: 68) reminds us that "No one is immune from these basic needs, temptations, and experience within the analytic setting." An important question concerns what factors might help or hinder good boundary maintenance. There are certain factors that we can attend to.

1. Supervisory engagement

McIlwain (2014: 58) reports on one research participant, stating that a situation concerning a client’s attraction toward him should require a consultation “immediately with a supervisor”, whereas if it were their attraction to a client, they stated “I don’t think that I would speak with my supervisor”. This latter response reflects the shame inherent in the profession with regard to sexual attraction toward clients, which in itself becomes a risk factor! Clinicians might reflect on any lack of supervisory presentation over time of the ‘genital erotic’.

2. Maintaining self-reflective practice

Note-taking concerning boundary choice and maintenance will support the practitioner. Maintaining our own emotional well-being is also essential, as well as reflection on our own view of our sexuality. Monitoring through self-assessment instruments can yield reflective material e.g. Boundary Violations Index (Swiggart, 2008).

3. Boundaries and the ‘slippery slope’ concept

The “slippery slope” concept (Gutheil and Gabbard, 1993) suggests that small boundary incursions paved the way toward boundary violations. However, withholding every boundary change may be at the cost of therapeutic benefits. Whilst the assumed correlation is not supported (Gottlieb and Younggren, 2009), it may still be used for reflective awareness. ‘Might I be allowing the boundaries to slowly drift?’ The answer might alert one to a potential counter-therapeutic occurrence.

4. Stress and depletion

Being stressed and lacking support and intimacy over time seem to make us much more vulnerable to ‘genital erotic’ boundary violations. Once on such an edge it is difficult to retreat. This is partly based in our physiology, as described by Helen Fisher (2008), in her TED talk The Brain in Love. She points out that once this particular reptilian core of the brain is activated, “you’re willing to take enormous risk for huge gains and huge losses”, there is a “willingness to risk it all” and “you distort reality”. This is dramatically enacted in the HBO series In Treatment where Dr. Paul Weston, a personally deprived practitioner, describes to his supervisor his love for his client Laura, and he states, “I love her. I want to be with her and I don’t care what it means and I don’t care what it costs.”

For our clients, the lesson is to ensure that we take sufficient self-care so that this point of ‘no return’ is not reached. Hopefully this map will challenge the shame that dominates this area and instead encourage a brave and open recognition of the erotic in the work that we do.

This article is an abridged version of a published chapter: Hitchings, P. (2020).

Paul Hitchings is a IAHIP qualified psychotherapist and a UK Registered and Chartered Counselling Psychologist. He relocated to Dublin in 2015 after 35 years in London. Over this period he has worked with individuals, couples and groups and taught on Masters and Doctoral level courses in Psychotherapy. He currently maintains a private practice and is currently completing doctoral research into the aftermath of post-ending experiences of practitioners ending with long term clients.

References:

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Black S. C. (2017). To cross or not to cross: Ethical boundaries in psychological practice. Journal of the Australian and New Zealand Student Services Association 25 (1), 62-71.
Celenza, A. (2010). The analyst’s needs and desires. Psychoanalytic Dialogues, 20:60-69.
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Fisher, H. (2008). TED Talk, ‘The Brain in Love’. Retrieved from: https://www.ted.com/talks/helen_ fisher_studies_the_brain_in_love?language=en#t-526977

Gottlieb, M. C. & Younggren, J. N. (2009). Is there a slippery slope? Considerations regarding multiple relationships and risk management. Professional Psychology: Research and Practice, 40 (6), 564.
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Pope K.S., Tabachnick, B.G. & Keith-Spiege, P. (1986). Sexual attraction to clients: The human therapist and the (sometimes) inhuman training system. American Psychologist, 41, (2): 147 – 158. Pope, K. S. & Tabachnick, B. G. (1993). Therapists’ anger, hate, fear, and sexual feelings: National survey of therapists’ responses, client, characteristics, critical events, formal complaints, and training. Professional Psychology, Research and Practice, 24(2), 142-152.

Sarkar, S. P. (2004). Boundary violation and sexual exploitation in psychiatry and psychotherapy: a review. Advances in Psychiatric Treatment 10, 312-321.
Smith Pickard, P. (2014). Role of psychological proximity and sexual feelings in negotiating relatedness in the consulting room – A phenomenological perspective. In Luca, M. (ed.) Sexual attraction in therapy. John Wiley.

IAHIP 2022 - INSIDE OUT 97 - Summer 2022