Essential Secrets of Psychotherapy: What's Love Got to Do With It? Part Two

Part One of this posting focused on the problem of love from the patient's side, and its central relevance to his or her symptoms and complaints. In Part Two, we take a look at how the healing power of love can facilitate the patient's treatment.

Psychoanalysis

, the prototypical form of psychotherapy pioneered and developed by Sigmund Freud and his protégé, C.G. Jung, has been called both the "talking cure" and, curiously, the "love cure." The love cure. In fact, Freud himself once said, in a letter to Jung, that "psychoanalysis is in essence a cure through love." What did he mean by this strange statement? Let's consider how and why love, even today, plays such an essential part not only in psychoanalysis or depth psychology per se, but in any successful psychotherapy.

Psychoanalysis

Last month at the Venice Film Festival, a controversial new movie directed by David Cronenberg called A Dangerous Method debuted to mostly positive but tepid reviews. The film, which I have not yet seen but definitely intend to, will be released here in the U.S. in November. A Dangerous Method is based on a book by John Kerr (and, later, a play) about Freud, Jung and a beautiful, brilliant and deeply disturbed female patient of Jung's, Sabina Spielrein. It is set in the formative early days of psychoanalysis, shortly following Freud's revolutionary publication of The Interpretation of Dreams in 1900. Spielrein (played by Keira Knightley) was referred for treatment to the Burgholzli, a Swiss psychiatric hospital in which Jung (played by Michael Fassbender) was completing his medical residency in psychiatry under the supervision of Eugen Bleuler, who coined the term "schizophrenia." Jung, not yet thirty and at that time a devout Freudian disciple from afar, decided to employ the master's psychoanalytic methods in his efforts to treat his very first patient, the terribly troubled, traumatized, probably functionally or borderline psychotic eighteen-year-old Ms. Spielrein. At some point during the course of therapy, they apparently became lovers. This sordid affair continued for several years, and caused a multitude of problems for the married Jung, as well as for Spielrein later on. And, once exposed, it precipitated the beginning of the end of Jung's close collaboration and friendship with the already famous Freud (played by Viggo Mortensen). But, despite all this, the fact is that Spielrein rather miraculously recovered from her severely debilitating mental illness, going on to become a physician and distinguished psychoanalyst herself. This was long before the advent of specific psychiatric medications routinely utilized today. So, clearly, Jung, despite his serious transgression, had done something right.

As I mentioned, this took place during the early days of psychoanalysis, in which Jung became Freud's closest colleague and co-worker in its development and dissemination. Indeed, the senior Freud for some time considered C.G. Jung his "heir apparent" to psychoanalysis once he himself was gone. Though both Freud and Jung were traditionally trained as physicians, psychiatry, like psychotherapy, was really still in its infancy. While, as medical doctors, they both recognized and had sworn to uphold the Hippocratic ethic of maintaining professional boundaries with patients, the concepts of what Freud famously came to call "transference" and "counter-transference," while taken for granted today, were still poorly grasped, and there had been limited opportunity for psychoanalysts to gain practical clinical experience contending with these powerful phenomena. So psychotherapy was, in this sense, still highly experimental. Freud had witnessed more than a decade before he gave birth to psychoanalysis, in the work of fellow physician Josef Breuer (see the case of Anna O.), how a female patient's erotic love (transference) for the physician could develop and wreak havoc with the medical treatment and doctor. This case marked, for Freud, the germination of what he eventually came to call "psychoanalysis."

The potentiality of love erotically entering into psychotherapy (or other professional relationships) is a constant peril. Such feelings are natural enough when two people meet regularly, discuss the most intimate matters, and when one regularly receives support, encouragement, empathy, respect, understanding and acceptance from the other. Since we all instinctively and sometimes neurotically need and seek love (see Part One), psychotherapists are susceptible to becoming the object of a patient's passionate admiration or ardor, and, in some cases, succumb to this tempting siren call, typically with catastrophic consequences for both parties. This is evidently what happened to the then young, susceptible and inexperienced Dr. Jung. And it would not be the last of Jung's extramarital affairs with one of his patients: Some years later, following his bitter falling out with Freud and excommunication from the psychoanalytic circle, he turned for support during his horrific mid-life crisis to Antonia "Toni" Wolff, whom he had previously been treating for depression. Wolff, who, like Spielrein, also later became an analyst, was, by Jung's own admission, his "other wife," with whom he maintained an open relationship for decades until her death. She helped Jung through his darkest period, during which he temporarily descended into psychosis, providing the additional love and understanding he evidently desperately needed after he had effectively helped her by providing his during Wolff's analysis. (See my prior posts on Jung and Jung's Red Book.) It should be noted that Jung's own highly conflicted childhood relationship with his mentally ill mother had been the source of great confusion, pain, distrust, feelings of abandonment, loss and anger, and can be seen, at least partly, as the cause of his compelling counter-transference reactions to these female patients. So Jung, who had never himself been in analysis, because of his own unconscious and unresolved "love wound," tended, in some early cases, to take the "love cure" quite literally. And he, unfortunately, was not the only analyst guilty of such unprofessional behavior.

Today, having learned from such mistakes over the past century, mental health professionals and the law recognize that it is never appropriate to physically sexualize the therapeutic relationship. This includes during the course of treatment, as well as, according to the American Psychological Association's Code of Ethics, for at least two years after termination of therapy. Even then, such behavior can be excused very rarely. If ever. In California, for example, and many other states, it is not only considered unethical, but illegal behavior, for which one can both lose his or her license to practice, be fined or even imprisoned. Sadly, despite these safeguards and strong dissuasions, sexual misconduct continues to occur in consulting rooms around the world. By some recent estimates, as many as 5-13% of male and 1-3% of female psychotherapists have had sexual contact with at least one of their patients. And, while these statistics may represent only the tip of the proverbial iceberg, the majority of malpractice cases filed each year can be attributed to exactly this sort of erotic acting out or "dual relationship" on the part of psychiatrists, psychologists and other mental health professionals. The reality is that, despite the rationalizations of irresponsible practitioners, turning the therapy relationship into a sexual or romantic one harms the patient in various ways and robs them of the psychological help they were seeking by entering treatment. Paradoxically, as psychoanalyst Erich Fromm points out, the patient has commonly come to psychotherapy, consciously or unconsciously, precisely because of problems concerning love. (See Part One.) They may be lonely or unhappy and seeking a companion or lover or looking for the attention, acceptance or physical affection they never received from their father or mother. But the solution is never for the psychotherapist to physically or romantically fulfill that role, which, when it occurs, amounts to a pathological playing out of his or her own personal problems--loneliness, neediness, selfishness, marital problems, possible narcissism, sociopathy, depression, substance abuse or psychosis--and unresolved "love wound" in the professional relationship with the patient. It is a profound and destructive abuse of power. An evil deed. This is one reason why the psychotherapist's submission to personal therapy while still in training and ongoing self-monitoring for such erotic counter-transference is so important in protecting the public and sanctity of the therapeutic relationship.

Providing psychological, spiritual or familial love is, of course, a different matter. At its best, therapeutic love on the psychotherapist's part may be most closely compared to amor platonicus (platonic love), agape, philia or storge, the nurturing love parents feel for their offspring. But eros, which Plato spoke of as a "great daimon," is perennially potentiated in both parties. How to provide such therapeutic love without overstepping the physical or romantic boundaries is part of the art of psychotherapy. How psychotherapists deal with the unexpected and unbidden appearance of eros, in themselves or their patients, in the transference or counter-transference, can make or break the treatment outcome. (See also my prior post on the power of termination in treatment.)

So what do psychotherapy patients really need? Is love enough? No. But there is little doubt as to the potent healing power of love, both in treatment and in life. Several decades after Jung's infamous misstep with Ms. Spielrein, American psychologist Carl Rogers, drawing on the discoveries of psychoanalysis, identified in his "person-centered" approach the importance of what he called "unconditional positive regard" and "reflective listening" in the therapy process, both of which are loving ways of relating empathetically to another human being. And Dr. Rogers, naively in my view, believed that if this loving approach could consistently be provided to the patient or "client" as he preferred to call them, it was all that's really needed for successful therapy. Perhaps for some. But, at least in my experience, patient's need more from their psychotherapist than love in this sense. They also need structure, limits, firmness, guidance, encouragement, confrontation, honesty, integrity and resolute commitment on the psychotherapist's part to accompany them on their personal journey through hell (and the unconscious) and back. Still, it could be said that these too are all aspects of love, as exemplified in what a loving parent provides to a troubled, injured or sickly infant, child or adolescent.

Psychotherapy--any form of psychotherapy--is primarily a relationship between two people. But it is a totally unique kind of relationship, unlike lovers, family or friends. Psychotherapists, especially psychodynamically-oriented therapists, are trained to make deliberate but limited and proscribed use of love's potent power to help patients heal. To heal from what? Almost always, patients suffer, fundamentally, from having been insufficiently or inappropriately loved (and this, paradoxically, can include being loved too unconditionally or excessively) during childhood, adolescence or adulthood. They suffer from what we can correctly call a "love wound," which manifests itself in many if not every aspect of adult life: from low or hyper-inflated self-esteem (e.g., as in depression, pathological narcissism and sociopathy) to poor sense of identity and self-worth (as in borderline personality disorder or dissociative identity disorder, for instance) to difficulties with intimacy and professional relationships, to the inability to love others as they are and life as it is. And it is only love--the right love at the right time--that can cure or heal this festering "love wound." No amount of technical tricks, to paraphrase the mature Jung, cognitive restructuring or pharmacotherapy will do. In fact, it could be argued that the real healing factor in Cognitive-Behavioral Therapy (CBT) or even, to some extent, psychopharmacotherapy, is the loving, supportive, caring, non-judgmental, empathetic relationship in which these popular treatments are provided. And this is corroborated by research suggesting that all forms of therapy (including pharmacotherapy) are effective primarily (or, at least in part) because of the special relationship between clinician and patient. But applying this alchemical love cure appropriately and efficaciously can be very tricky indeed.

For what patients receive from the psychotherapist is not necessarily the love they want. It can never be a physical expression of love. Nor should it take the form of verbal flirtation or romantic interchanges between therapist and patient. For this--while it may be what the patient wants from the therapist or vice-versa--is not what the patient truly needs. Therapeutic love cannot be sexualized or romanticized, though such feelings frequently find their way into the consulting room. When they do so, the key, for both patient and therapist, is never to act on them. But, at the same time, not deny them. To acknowledge, honor and reflect upon these passionate feelings, but not to impulsively act them out. Talking openly about such transferential feelings is essential for the patient and to the process. But not in same way lovers talk. And such direct talk is not considered constructive in the case of erotic counter-transference on the part of the therapist, who has a duty to either manage it so it doesn't derail treatment or refer the patient to a colleague. So erotic love can and sometimes does interfere with treatment. Especially when it takes possession of the psychotherapist and won't let go. But, more often than not, when properly handled, love provides the basic curative power in therapy. Love in psychotherapy, as in any healthy, mature relationship, is a two-way street: Love (or libido, as both Freud and Jung used the term, though Jung's definition was far broader) flows from the psychotherapist and back from the patient. So it is not just the love provided by the therapist that matters, but the love returned by the patient that is ultimately the healing factor in treatment. Remember (see Part One), many (but not all) psychotherapy patients suffer from an inability to love, a blockage in their willingness to open their hearts, commit to and care deeply for another. To let down their defenses. To be themselves. To risk being rejected, hurt or abandoned. For patients suffering from such "intimacy inhibition" or "love phobia", much of the psychotherapy session is spent actively or passively, almost always unconsciously, fending off such loving feelings, much as they do elsewhere. But why? Especially since love is what they really want?

The psychotherapist's offering of non-physical or platonic love to the patient is what encourages, stimulates and enables the patient to gradually reciprocate in kind. To open up to love. To tolerate love's anxiety and ambiguity. To risk letting love happen, to experience it, to allow the vulnerability of intimacy. To relinquish control and be more receptive to love. For the patient, romantic, sexual or, as Freud referred to it, erotic transference, is powerful, impassioned and, when recognized for what it really is and handled properly, transformative, since it is typically a manifestation or expression of the core love wound caused by imperfect parental relationships. Transference (which can also sometimes turn negative and nasty) is the royal road right into the very core "love wound" complex. But becoming more receptive to love means being willing to gradually and painfully tear open the old love wound. This core love wound typically contains a repressed reservoir of rage, grief, hurt and sadness from the past, all of which must be slowly allowed to surface, flow and be consciously felt. But it also holds immense libidinal energy in the positive sense. This libidinal energy is daimonic, which is to say that it is uncannily powerful, and can be both destructive and creative. If the erotic transference can be handled properly, without dismissing, denigrating or rejecting it, while at the same time firmly maintaining clear and consistent boundaries, this newly liberated libidinal energy or love from the patient can be redirected out into his or her life beyond the therapist's office. For now, the patient has once again experienced love, at least to some degree, albeit in the relative safety and security of the sacred container or temenos of psychotherapy. Once the patient regains or reawakens to this vital, child-like capacity to love, to care, to open oneself to another, or, in a more spiritual sense, to the existential reality, tragedy, suffering and beauty of life and death, he or she is prepared to try doing so in that great big world beyond the secure yet constricted womb of therapy. He or she is ready for love. And for life.