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Clinical Case Conference   |    
Dilemmas in the Psychotherapy of Sexually Impulsive Patients
Glen O. Gabbard, M.D.; Tanya J. Bennett, M.D.
Am J Psychiatry 2005;162:859-865. doi:10.1176/appi.ajp.162.5.859

Psychoanalytic therapy emerged from a sociohistorical era of repressed sexuality, and Sigmund Freud originally thought that "dammed-up libido" might be responsible for certain types of neurotic psychopathology. Much of the treatment was geared toward making patients consciously aware of their unconscious sexual wishes and the tenacity of their defenses against them. More than a century has passed since then, and the cultural context of sexuality in the early 21st century bears little resemblance to Victorian Vienna. Twelve-year-old girls emulate Britney Spears in their apparel. Teenagers are exposed to explicit sexuality on cable television and in the local cineplex. Raw sexuality is ubiquitous in advertising, on magazine covers, and in television commercials.

Patients who come for psychodynamic/psychoanalytic therapy today are far less likely to be seen with sexual inhibitions or conflicts. Indeed, sexuality may be a relatively minor issue in their presenting clinical picture. The sexual preferences, fantasies, and practices of today’s patient may not even emerge until the process is well launched. Moreover, when sexual material does enter into the psychotherapeutic dialogue, it may be incidental to the main theme of the treatment and be entirely egosyntonic. The patient may express no interest whatsoever in changing sexual practices, and the therapist may need to accept the patient’s right to set the agenda for the therapy. These cases may present extraordinary challenges for the therapist because of their potential to cause harm to the patient.

When I first met Ms. A, a 25-year-old woman, she was sobbing uncontrollably in the waiting room at the Baylor Psychiatry Clinic and was about 20 minutes late for our appointment. She had called the clinic earlier on her cell phone, reportedly lost and panicky, and had pleaded with clinic staff not to hang up until her arrival. In the interview room, Ms. A calmed down quickly and apologized for her tardiness and behavior. She appeared very assertive and remained dramatic even after she had regained her composure. I was immediately struck by her physical beauty, impeccable grooming, and stylish clothing. Her chief complaint was "my medication isn’t working," and she stated that she had had depression and anxiety since age 10. She recounted numerous recent stressors, most notably her marriage a few months earlier. Her life had changed in many ways, including that she no longer needed to work or attend school, and she alluded to this transition as fairy-tale material, a dream come true. Despite this development, she endorsed multiple symptoms of depression and felt confused and purposeless. She ruminated about how horrible she was, sometimes for hours before falling asleep each night, and engaged in excessive apologizing. She complained of constant worry and expressed concern that her moods were up and down and out of control. She also described several episodes of what she called "paranoia" that involved people looking at her or following her—experiences that sounded credible rather than delusional.

Ms. A had been in psychotherapy for the presumed treatment of depressive symptoms with a well-respected psychiatrist and family friend from the ages of 13 to 16. During this time, she had not received any medication. She had had no subsequent psychiatric care until age 24, at which time she sought help for depression and anxiety, was given a prescription for an antidepressant, and saw a psychiatrist every 3 months or so for medication management.

Her pertinent medical history included very painful menstrual periods since menarche and monthly treatment-resistant vaginal infections since she became sexually active with her husband. She also reported a past history of polysubstance abuse, reportedly in full remission for 2 years.

Her developmental history was significant in that she was the third of three children born to first-generation immigrants. Ms. A’s mother was reportedly told that she could not get pregnant again after Ms. A’s birth. Ms. A described her mother as depressed, overly protective and manipulative, and chronically ill with multiple health problems. Her mother was also the daughter of two victims of severe trauma, and her maternal grandmother reportedly "went crazy" after her grandfather’s death. Ms. A’s father worked until late at night, and Ms. A described her childhood as spent primarily with her mother. She described herself as a rebellious, argumentative adolescent who frequently fought with her mother, who would laugh openly at her the angrier Ms. A became and who would punish her by not speaking to her for days. During her school years, she felt that she did not belong and had few female friends but always wanted them. She attributed this to their being jealous but hesitated to link it to her beauty. She added, however, that despite everyone always telling her that she was beautiful, she didn’t know if she believed it or not.

When asked what her goals were in coming to the clinic, she stated that she wanted to get her medication adjusted and was interested in therapy. When asked what she would like to work on in therapy, she stated that her main concerns were her inability to show her husband how much she loved him and to "calm… down." I diagnosed her with dysthymia, anxiety disorder not otherwise specified, and polysubstance abuse in full remission based on her history. I made a mental note of her histrionic traits, restarted her antidepressant, and scheduled our first therapy session for the following week.

Ms. A started our first therapy session by joking about a recent dream. In the dream, her husband and his sister were having sex in a room with a large plate-glass window. Her husband was fondling his sister’s nipples. Ms. A was outside watching them through the window. Her husband rose up partially from the missionary position in obvious enjoyment. He turned and looked at her and smiled. She did not attempt to work with the dream in therapy and seemed uninterested in its meaning. For the next 7 months or so of therapy, Ms. A would come in, sit down, and start talking, not stopping until the session was finished. As her dream suggested, she focused primarily on her feelings of isolation and being an outsider. She also felt that she did not know who she was anymore or what she wanted. She could not separate her own needs and desires from her husband’s. She grappled with the things rich people do, which she often viewed as shocking or wrong, and the demands of her new role as a wife in a well-known and socially visible family. She spoke "at" me rather than "to" me in a rapid and dramatic (but not pressured) manner and would often talk through my occasional comments or interrupt me before I had finished. If I did finish, she would ignore, disregard, or minimize my comment almost immediately. I felt angry, frustrated, and inadequate. I might as well not have even been in the room. The sessions felt completely beyond my control, and I anticipated them with dread. I was gradually becoming aware of a characterological style that made me wonder about borderline or histrionic traits, especially because her depressive and anxiety symptoms appeared context-dependent.

Ms. A’s first dream communicated important themes to Dr. Bennett while she simultaneously disavowed them as "just a dream." In effect, she showed a compromise between telling and not telling her therapist about her sexual concerns. Because Ms. A did not provide extensive associations to the dream, we could not be certain of its meaning. However, the manifest content was highly suggestive. Ms. A was an observer watching her husband engaged in incestuous sexual relations with his sister. She was feeling excluded from something forbidden. She felt hurt and betrayed. The characters in a dream are often like the dramatis personae of a play, with each of them representing different aspects of the dreamer—both self and object representations that may be conscious or unconscious. Hence, one way to understand the dream is that Ms. A may also have been revealing to Dr. Bennett an important aspect of herself, a feeling of always being an excluded onlooker. Indeed, Dr. Bennett then told us that she, too, often felt like an outsider in the early months of therapy. As she put it, she might as well not have been in the room. Ms. A was beyond her control in the same way that, in the dream, Ms. A’s husband was out of her control. Hence, we can speculate that Ms. A may have recapitulated an internal drama depicted in the dream but with the roles assigned differently. By "performing" for Dr. Bennett, Ms. A was in the role of the sexual performer in the dream while Dr. Bennett was identifying with the part of the patient that felt like an outsider looking in. Some patients convey who they are not by a clear narrative of their inner world but by making the therapist feel as they do. In technical terms, we might refer to this phenomenon as a projective identification of a self-representation rather than as an objective representation from the patient’s inner world. This identification with the patient helps the therapist empathize with the patient’s experience. The patient’s jocular attitude may have expressed a need to distance herself from the dream by making fun of it with her therapist and dismissing its importance.

After about 7 months into therapy, Ms. A came in one day and stated, "I haven’t been honest with you…. I haven’t told you about a big part of my life because I’m scared you won’t like me." She then proceeded to tell me about her sex life, which included sadomasochistic sex with her husband as well as their "swinging" lifestyle. This was somewhat awkward because I did not know what "swinging" meant and said so. This obviously pleased Ms. A, who smiled and laughed a little, stating that now she could teach me something. She proceeded to define swinging as similar to dating but for couples rather than individuals. I simply listened as she described a meeting that she and her husband had with a couple for dinner and drinks. After dinner, they went to a hotel room together, where they talked some more, including about what they liked sexually, and then had sex. Ms. A stated that the sexual activity consisted of male-female or female-female kissing and touching, followed by intercourse with one’s spouse while the other couple watched. She stated that they would always talk about everything afterward and that she really liked this part of the experience. In terms of the sadomasochistic sex, this was something that she and her husband did alone together. She vaguely described him as the aggressor, downplaying it as all in fun—nothing serious—but did not supply any details at this time. Somewhat defensively, she stated that her husband believed that if it felt good, do it, and that what two or more consenting adults did privately was their own business and that they should not be judged negatively for it or considered freaks. She added that she agreed with him and that she loved sex, had always wanted lots of sex, and couldn’t get enough. She also talked about "wanting to know women" and about how she had never had any close female friends and craved this intimacy. Ms. A openly questioned her sexuality and the conventional societal definitions of heterosexuality versus homosexuality. She defined sexuality as more of a spectrum.

During this session, I felt like I was caught up in an embarrassingly riveting made-for-television movie. The content was titillating, and Ms. A was obviously aware of this and enjoyed the delivery. Her dramatic tone made it very easy to visualize the foursome. I also remember picturing the shock on my supervisor’s face as I told her about this session. I did not feel particularly concerned for Ms. A’s safety at the time. She had essentially described the swinging as talking, petting, and sexual intercourse only with her husband and had minimized the danger involved in the sadism and masochism. It felt like she had customized the script on my behalf—emphasizing the talking, openness, and honesty and downplaying the risks. Perhaps because of this, I did not feel repulsed by her actions or judge her negatively for them. It did not cross my mind that this was perverse or deviant but instead seemed more playful or exploratory. I found myself rationalizing the behaviors right along with her. In general, I agreed that, for the most part, what consenting adults did in private was indeed their business, as long as they were not hurting themselves or others. I also agreed that sexuality is not always black and white. Despite this, I felt uncomfortable and awkward. This intensified when she stated that several couples they had met while swinging were medical doctors and nurses. This bothered me more than her telling me about her participation in the swinging. It felt too personally intrusive, too close to the realm of possibility. It made me feel further isolated and somehow judged negatively by the patient, as if I were the outsider, not one of the group. Just as important, however, I felt relief. A "secret" had been revealed in the therapy that I found very frustrating. I now had renewed enthusiasm about the therapy and, with it, some small sense of control and guarded optimism that the therapy would now progress. I was concerned that this disclosure occurred 7 months into therapy and felt somewhat staged, but given her expressed desire for intimacy with women, this seemed to make sense at the time in terms of her fear that we would lose our connection.

The theme of voyeur/exhibitionist pairings heralded by the initial dream was given further elaboration after 7 months of therapy, when Ms. A described her practice of "swinging." Although she was naive about this practice, Dr. Bennett strived to listen in a nonjudgmental and accepting way. She was a well-trained dynamic therapist who knew that at the heart of the psychodynamic approach was a profound respect for the patient’s individual right to live as she wished without imposing judgment or exhortations to change. After all, she reasoned, these are consenting adults, and there was no apparent harm to anyone. Her husband was not forcing Ms. A to engage in these foursomes. She enjoyed the sex and looked forward to it. Dr. Bennett was an observer of a fascinating narrative that was alien to her, lending a "cross-cultural" perspective to the therapy. She was a psychiatric version of a cultural anthropologist in her consulting room, eavesdropping on the sexual practices of creatures from a stratum of society that were not within her experience. When Ms. A noted that doctors and nurses were involved, however, Dr. Bennett started feeling uneasy, sensing that the stories were becoming a bit too close, encroaching on the borders of her own turf at an academic medical center. She was also drawn to the theatrical aspects of the presentation. It was like watching a television movie. The "staged" feeling of the proceedings helped her keep her distance. The pleasure in watching and showing, of course, can be understood as an enactment of the patient’s sexual inner world. As noted, the narrative of words and events has its nonverbal counterpart in the enactment of a sexualized scenario within the therapy. A fundamental psychodynamic principle is that each patient re-creates his or her internal object world in the therapeutic setting.

Over time, Ms. A continued to reveal more detailed and explicit accounts of her sexual behavior. She and her husband often attended private swinging parties and frequented swinging clubs most weekends. Her description of these events featured rooms full of naked people drinking, talking, and involved in various sexual acts, some behind closed doors and many not. Threesomes and foursomes with spectators and participants changing roles were common. Ms. A actively sought out the largest, most overtly aggressive men at these events and would engage in intercourse, oral and/or anal sex with them, most often while her husband watched. The female-female sexual behavior also progressed to oral sex, with Ms. A always the "giver" (because she refused to be a recipient). This contrasted with her sex life with her husband, which never included oral sex. She continued to present this material in a dramatic manner that seemed designed to maximize its shock value. Ms. A recounted these events with a remarkably theatrical flair, including dramatic (dare I say "pregnant"?) pauses for effect when she appeared to be gauging my reaction. I did my best to respond in a consistent and nonjudgmental manner, but I worried increasingly about her safety. When I brought up this concern, she would rapidly reassure me that she always used condoms and that her husband was always there.

The sessions became even more graphic. She described "sex-a-thons" that involved going to conventional bars with her husband to pick up large, athletic men and bring them home. She and the chosen man would then have loud, aggressive sex for hours at a time, as she described it, while her husband listened downstairs. She also boasted repeatedly about her talent for pleasuring women in ways that amazed both the women themselves and their husbands. Often, she said, husbands or male partners would ask her afterward to teach them her technique. As I listened with fascination, I realized that the sessions had begun to feel like peep shows. I found myself actively disliking Ms. A for the first time and judging her somewhat contemptuously for participating in these sordid events. I also felt a degree of self-loathing for my role as a captive audience that had been dragged into these "show-and-tell" sessions. Nevertheless, I attempted to maintain the superficial demeanor of a concerned and interested neutral therapist. As her participation in this sexual lifestyle intensified, I worried that my nonjudgmental manner was actually encouraging her behavior. The sessions felt even more out of control, in delivery and now in content.

Dr. Bennett found herself in a real dilemma here. She was starting to feel dismayed by what she heard and contemptuous toward her patient. Yet she felt the therapy demanded her to be accepting of alternative sexual practices that were far from her experience and, from her perspective, morally questionable. Was her effort to present herself as accepting and nonjudgmental a form of collusion in which she is playing voyeur to the patient’s exhibitionist? Was she tacitly endorsing the behavior by not questioning it more vigorously? Yet if she did challenge it, Ms. A could, with some justification, accuse her of moralizing about her preferred sexual practices. After all, no children were involved, and no crime was being committed. Ms. A might simply clam up and stop talking about what she did in the privacy of her many "bedrooms." Moreover, in response to feeling judged and criticized, she could conceivably quit the therapy and never return. Dr. Bennett felt stuck in a "damned if I do and damned if I don’t" situation.

Yet to her credit, Dr. Bennett was able to acknowledge her feelings of anger and contempt, at least to herself and to us. A psychodynamic therapist has no obligation toward political correctness in the domain of her private thoughts. She reacted in whatever way she felt and noted her feelings to herself in a way that may be useful in therapy. Was she reacting like others react to the patient? Was her reaction in some way idiosyncratic? As Sandler (1) suggested in his classic article on role-responsiveness, the therapist must maintain both free-floating attention and free-floating responsiveness. The decision to share those feelings with the patient was far more complicated and must be carefully considered in each individual case.

Ms. A came in one day and casually mentioned that her husband had arranged a date for the two of them. She nonchalantly joked that her husband was like a pimp and chuckled about her analogy. When asked more about this, she casually stated that this was nothing new; her mother had done the same thing. She then described how her mother used to dress her up "like a doll" in a "princess dress" and take her to see her father at work at a bar. She would then be placed on a bar stool (she was too small to climb up herself) and was expected to smile, chat, and generally entertain the "regulars." When her father wasn’t busy, she would be available to spend a couple minutes with him. Most frequently, however, she remembered these nights as consisting of older men of varying degrees of intoxication fawning over her, buying her pretty drinks, and telling her that she was a beautiful little girl. This went on throughout her childhood, starting from around the time she was 3 years old, at least once a week until closing time. As an adolescent, her mother would set up dates for her with friends’ sons or young men she had met and deemed appropriate. Ms. A would then inform her mother of their specific plans, and, unbeknown to the date, her mother would watch from nearby. At this point, my face must have revealed some degree of amazement or concern because she paused and then added that she told her mother everything, even about the swinging. When I asked how her mother had responded, she said that her mother had told her about a lesbian encounter that she had "almost" had but "didn’t go through with." It seemed a source of pride to both mother and daughter that Ms. A had actually gone through with these experiences. I asked her how she felt telling her mother about such things. She snickered, stating that her mother had been dressing her in sexually provocative clothing since she was a young child. I then made a comment about how difficult it must be to be someone else’s plaything, and she shrugged, stating that she was used to it by now. In this regard, it is important to stress that Ms. A always expressed thorough enjoyment of the swinging, despite her husband having been the one to initiate these experiences.

Dr. Bennett could no longer contain her forced neutrality at this point. Ms. A noticed that she was amazed and concerned and took time out from her narrative to explain that she told her mother everything, as if to say to Dr. Bennett that she had to do the same with her therapist. In making the assumption that at some level Ms. A must have felt used and exploited by her husband in the present and by her mother in the past, Dr. Bennett made an empathic comment that it must have been difficult to be someone else’s plaything. Ms. A shrugged off the comment by reassuring her therapist that she was simply used to it, implying that it no longer bothered her.

The therapist was faced with a dilemma of increasing complexity here. Embedded in the notion of two consenting adults is freedom of choice. Two adult sexual partners are constitutionally free to do whatever they like when they are in private, so we mental health professionals should suspend judgment and let our patients seek whatever form of sexual gratification they like. But here’s the rub: is choice always free? Is a woman who is beaten during incestuous sexual relations with her father throughout her childhood then "free" to "choose" that lifestyle as an adult with abusive male partners? With our growing knowledge of the compelling need to repeat traumatic relationships (2, 3), can we really stand by in such cases and say that the patient is simply "choosing"?

Ms. A was clearly repeating a pattern from her childhood that felt obligatory at some level. To make her mother happy, she had dressed up like a party doll and functioned as a plaything to a host of inebriated men in a bar. Now she was reenacting that childhood scenario with her husband and to some extent with her therapist. When Dr. Bennett attempted to empathize with the degrading aspects of the experience, Ms. A brushed off her help. Sexually impulsive or compulsive patients are often treated today with an approach that emphasizes impulse-control training, 12-step groups, relapse prevention, cognitive restructuring, and social learning (4). This approach requires a patient who is willing to view her sexual behavior as a problem and is interested in forming a collaborative alliance with a therapist as part of a systematic treatment plan. Ms. A expressed no interest whatsoever in changing her behavior. What was Dr. Bennett to do?

As Ms. A continued to relay her sexual experiences, a degree of ambiguity gradually surfaced. During one session over a year into the therapy, she stated that her husband had complained that she always "zoned out" before a party or before going to a club. He was annoyed because it appeared that she didn’t want to go out. Ms. A then described a period of several hours’ duration that typically occurred preceding swinging events. She would essentially dissociate at these times, becoming nonresponsive to others, focusing internally, and attempting to self-soothe. She stated that she needed to do this to "prepare" for the evening and that once she was at the event, she was able to smile, socialize, and have sex. She spontaneously connected this to a memory from her childhood. Throughout her childhood and adolescence, Ms. A was "strongly encouraged" by her mother to model. As a young child, she was a runway model for a department store chain. She vividly recounted an experience when she was 3 years old: it was before a fashion show, and she was backstage with her mother. She was crying and screaming that she did not want to do it. She had tears running down her face, and her makeup and hair were getting ruined. Her mother became very angry, yelling and swearing at her to "do it." She struggled with her mother, still crying that she didn’t want to do it. Her mother pushed her onto the runway, yelling in a more hushed tone, and suddenly she was out on the runway, and everyone was staring at her. She paused, remembering the dress as pink and black with ruffles, and then stopped. I asked what happened next. She sarcastically responded, "What do you think happened? I stopped crying and did it." She then casually added that it was the same with swinging, that she needs to prepare for the performance, but once "on," she can "do it."

Ms. A often relayed snippets of her childhood that were as dramatic and "shocking" in both delivery and content as those regarding her sexual exploits. Oftentimes these memories were as uncomfortably tantalizing as listening to her describe her sexual exploits. Frequently, they seemed intertwined. Whereas I often revisited my internal struggle over my attempt to remain nonjudgmental regarding her swinging, I had no hesitancy whatsoever voicing my judgment regarding her childhood experiences with her mother. I could not help but think of my own daughter when listening to Ms. A at these times and knew in my gut that my patient’s childhood experiences were unequivocally wrong. When Ms. A relayed such childhood memories, I responded empathetically and supportively, emphasizing how horrible such things must have been for her and validating her view of her mother as a very controlling, selfish, and, at times, downright sadistic woman. At first, Ms. A resisted this intervention, stating that she loved her mother and knew she had done "the best she could." I did not dispute this but kept emphasizing how horrible the scenarios were that she described and how hard it must have been to develop one’s own self when one’s primary caregiver had such a dominant personality. This approach seemed to calm her, and she seemed to consider what I was saying for the first time. In terms of content, she gradually shifted to talking less about her sexual exploits and more about her childhood. She became more open about her insecurities regarding being female, including her discomfort with her body and its femininity.

Here Dr. Bennett found an ingenious way to form a therapeutic alliance with Ms. A. Rather than taking a judgmental stand on Ms. A’s current sexual practices, she focused her attention on childhood experiences that we can view as the antecedents of her current sexual behavior. Here she could join the patient in a sense of outrage about a "stage mother" who forced her own agenda on her daughter. By frankly sharing her horror at the modeling stories, Dr. Bennett facilitated a feeling of validation in Ms. A. This sense of having her experience affirmed helped build trust and a sense of feeling understood in the therapy. While it is often risky to take sides against a patient’s mother, Dr. Bennett finessed this problem by focusing on the horror of the experiences rather than any sort of absolute "evil" in the patient’s mother.

In terms of the transference, the room felt warmer. The countertransference thawed a bit, too. I began to like Ms. A. I worried about her over the weekends and wanted to keep her safe and protected. To a large extent, I felt like I was mothering an adolescent. She continued to discuss material that was just as fantastic and sexually explicit as ever, but her motive seemed to be less to titillate or "shock" and more to share. She appeared to hear me when I expressed my dismay or concern. Finally, her behavior started to change, and her general impulsivity (angry outbursts, reckless driving, and alcohol use) began to diminish.

Ms. A had a difficult time with my canceling appointments, regardless of the advance notice. Despite my consistently outlining coverage in my absence and/or giving her a cell phone number to call, she developed a pattern of canceling her last one or two appointments before my scheduled absences. During several sessions before one such scheduled absence, we delineated a plan for a weekend during which her parents, her husband, and I would all be gone. Ms. A had stated repeatedly that she knew that she would just want to "go out…act crazy…do something impulsive." She described herself as "horny" and did not think she could resist the urge to have sex. In spite of these statements, I sensed an ambivalence to act. Her tone was less passionate, her words lacked certainty, and she seemed to be looking for a way out. It felt like she was taunting me in an adolescent manner, as if daring me to discipline her. We discussed alternative behaviors that she enjoyed, such as reading and playing with her pets. I asked about masturbation with some trepidation, and she snickered, stating that she had already thought of that and had plenty of "toys" to keep her occupied, adding, "but it just isn’t the same." I emphasized that it was a lot safer and positively reinforced how well she was doing caring for herself, thinking and talking rather than doing. I also asked her to picture me telling her to be safe and to tell herself "don’t do it" if she thought she was going to do something impulsive and potentially self-harmful. She laughed and said she would. She then canceled the last session before this weekend, stating in her voice mail message that she knew I would think she was canceling because I was going away but really she had other things she needed to do and no other time to do them. At our first session after the weekend, she laughed when she described what she had done that weekend—stayed home alone, played with the pet, and read. She stated that she had come close to going out and being "wild" several times but was overtly proud that she hadn’t. I was proud of her and derived pleasure out of being her "good mommy."

More than 2 years into the therapy, Ms. A stopped swinging. This correlated with her attempts to get pregnant. She originally did not talk of giving up this lifestyle entirely or permanently but, rather, temporarily to "keep healthy" while she became pregnant. On several occasions, I asked her how she planned to incorporate parenting into this lifestyle. She stated matter-of-factly that many of the swingers had kids and that some had even been present (in different parts of the house) at private parties. Although I never verbalized any disapproval regarding this, I am sure that my nonverbal distress was clearly apparent to this very sensitive patient. Over time, she talked more about the kind of parent she wanted to be and her concern regarding her husband as a parent. She maintained her confidence that she would be a good mother and ultimately decided she would not want to do both. Concurrently, she and her husband moved from an apartment to a new condominium. Ms. A would talk about her new home, the tree-lined sidewalks, the quiet street, and how a baby was all that was missing from this "perfect" life. This appeared to be a kind of substitute fantasy. She defined this time period as "calm" but always voiced distrust of it, unsure whether or when "the other shoe [would] drop." Outwardly, she was containing her impulsivity and becoming more productive. She completed coursework and passed the certification examination to become a personal trainer and started work part-time at a women’s fitness center. She found working exclusively with women very rewarding and genuinely enjoyed the work. Inwardly, she still "craved" sex and missed the excitement and physical pleasures of the swinging. She talked about this, likening herself to an "addict," stating that she was learning to resist her "urges" but that sometimes it was "1 hour at a time."

Her husband was very unhappy with her decision to give up swinging, despite her unwavering and even increased desire to have sex with him. He continued to pressure her to start swinging again and stated that he no longer wanted children. She acquiesced to his demands for no children "for the sake of the marriage" but did not start swinging again. It had been almost 1 year since she last attended or participated in a swinging event. She and her husband had very little sex and maintained a civil roommate-like day-to-day existence. Despite her desire for more sex and her stated desire to save the marriage, she appeared unwilling to reenter the swinging lifestyle.

She then purchased a vibrator. She actually blushed when telling me this and quickly noted the irony, that of all of the things she had told me, this was the first thing that had embarrassed her. Unlike previous sex toys, this vibrator was purchased exclusively for herself, and she made the decision without consulting or informing anyone. She planned on using it by herself, not as a prop with her husband or others. I again emphasized how well I thought she was doing and how far she had come in terms of containing her impulsivity and keeping herself safe. I then told her that she should pat herself on the back, to which she responded, "No. You should pat yourself on the back," and we both, literally, patted ourselves on our backs.

Such exchanges started out somewhat in jest when Ms. A’s behavior became more and more self-contained and have become more frequent as she has improved: I congratulate her for her good work. She typically responds that it was my doing. We both agree that it was our good work, and we both pat ourselves on our backs. This time, however, she finished her patting and told me that at the end of each exercise class that she teaches, she tells the women to pat themselves on the back, and at the end of her day (seven classes some days), she pats herself on the back as well. I felt very touched by this image, not just in terms of professional pride for the work we have done but on a more visceral level, like when I watch my daughter doing or saying something that seems all too familiar and then realize it is because she is, on a very concrete level, emulating me.

In this extraordinary piece of therapeutic work, Dr. Bennett had to avoid a particular minefield involving the repetition of specific patterns of the patient’s internal object relations in the therapeutic relationship. Ms. A was haunted by a sadistic, demanding object representation that insisted on compliance with its wishes. While the original model for this internal object may have been her mother, it was reenacted on a regular basis with her husband in that role. Her corresponding self-representation was one of a compliant child who would deny her rage and helplessness and "prepare" herself for submission to the demands. The therapist’s minefield is the almost magnetic pull to start telling the patient what to do and what not to do, which feeds right into the familiar paradigm in the patient’s internal object world. To some extent, this is unavoidable, but to her credit, Dr. Bennett largely avoided the position of criticizing Ms. A for her sexual practices by focusing primarily on her personal concern about Ms. A’s safety. Although the patient obviously read expressions of concern and disapproval in Dr. Bennett’s face, the therapist did not assume the role of a critical, nagging mother who told her that what she was doing was wrong. Hence, Ms. A began to see her as a "good mommy" who had her best interests in mind, a new object-relations paradigm that was foreign to Ms. A. One way to understand the mode of therapeutic action in this case was to assume that a new neural network, consisting of a caring, concerned object representation and a self-representation that engaged in self-care and gained approval from doing so, was gradually strengthened as the old neural networks of problematic relatedness were relatively weakened. Another way to conceptualize what happened is that Ms. A’s behavior was gradually transformed from egosyntonic to egodystonic. In other words, what she initially insisted was entirely acceptable and fun for her was converted to problematic status in her mind. We can speculate that Ms. A projected one-half of her ambivalence into Dr. Bennett—namely, the part that regarded the sexual practices negatively. Over time, Dr. Bennett contained that portion of Ms. A’s feelings until Ms. A could take that back and "own" it as her own feelings. While both transference and countertransference were important constructs to understand what was happening, Dr. Bennett did not actively interpret transference to Ms. A. She also encouraged a sense of agency in the patient by refusing to take credit for all the improvements that had taken place, thus assisting the patient in developing a sense of self separate from being a passive recipient of the wishes of others.

Received Nov. 5, 2004; accepted Jan. 24, 2005. From the Menninger Department of Psychiatry, Baylor College of Medicine. Address correspondence and reprint requests to Dr. Gabbard, Menninger Department of Psychiatry, Baylor College of Medicine, 6655 Travis, Suite 500, Houston, TX 77030 ; ggabbard@bcm.tmc.edu; (e-mail).

Sandler J: Countertransference and role-responsiveness. Int Rev Psychoanal  1976; 3:43–47
Allen JG: Traumatic Relationships and Serious Mental Disorders. New York, John Wiley & Sons, 2001
Bateman A, Fonagy P: Psychotherapy for Borderline Personality Disorder. New York, Oxford University Press, 2004
Fagan PJ: Sexual Disorders: Perspectives on Diagnosis and Treatment. Baltimore, Johns Hopkins University Press, 2004


Sandler J: Countertransference and role-responsiveness. Int Rev Psychoanal  1976; 3:43–47
Allen JG: Traumatic Relationships and Serious Mental Disorders. New York, John Wiley & Sons, 2001
Bateman A, Fonagy P: Psychotherapy for Borderline Personality Disorder. New York, Oxford University Press, 2004
Fagan PJ: Sexual Disorders: Perspectives on Diagnosis and Treatment. Baltimore, Johns Hopkins University Press, 2004

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