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Psychotherapeutic issues with "kinky" clients: clinical problems, yours and theirs.
People whose sexual repertoire includes BDSM, fetish, or other "kinky" practices have become increasingly visible, on the Internet, in the real world, and in psychotherapists' offices. Unfortunately, the prevailing psychiatric view of BDSM remains a negative one: These sexual practices are usually considered paraphilias, i.e., de facto evidence of pathology. A different, affirming view of BDSM is taken in this paper. After defining BDSM and reviewing common misconceptions, a variety of issues the practitioner will face are described. These include problems of countertransference, of working with people with newly emerging sexual identities, working with spouses and partners, and discriminating between abuse and sexual "play."
Investigating bias in psychotherapy with BDSM clients.
There is a concern among consensual BDSM participants that they will receive biased care from mental health professionals. Results are presented of an anonymous Internet-based survey administered to both BDSM-identified individuals who have received psychological care and to mental health professionals. The survey included socio-demographic data and invited participants to write narrative accounts of biased or culturally sensitive care, from which common themes were identified. Mental health providers (N=17) responded in fewer numbers than those who identified as BDSM-identified participants (N=175). Descriptive characteristics of the sample will be discussed. Themes from the qualitative data may be useful in informing the future development of guidelines for practitioners to work more responsibly with clients who identify as members of this sexual minority group.
Learning from extraordinary lovers: lessons from the edge.
This paper discusses lessons about sexuality and eroticism gleaned from those who engage in extraordinary sex, even though such relationships have typically been classified as pathological. What can clinicians learn from those who seek and attain uncommon sexual relations? Such individuals' sexual epistemology, goals, understanding of the nature and spectrum of sexual and erotic relations, communication strategies and "outcome" criteria can provide valuable lessons for those who treat sexual problems or aim to overcome sexual mediocrity. For example, while traditional sex therapy often focuses on what is on the surface, some SM participants are interested in the meanings that lie at a deeper level. Whereas conventional clinicians may focus on enabling particular sexual acts (especially heterosexual intercourse), SM participants are more apt to be concerned with the varied spectrum of underlying purposes motivating these acts. Whereas many couples are willing to settle for merely functional sex, SM practitioners may be more interested in contact that necessitates intense, erotic connection; sophisticated communication of subtle differences in intent; and eventuates in profound self-knowledge and transcendent levels of intimacy. Illustrative case examples are provided.
Playing doctors: refiguring the doctor-patient relationship in Hervé Guibert's AIDS novels.
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Refusing the cure: Sophocles's Philoctetes and the clinical problems of self-injurious spite, shame and forgiveness.
Sophocles's Philoctetes (409 BCE) is a dramatic masterpiece unfamiliar to most analysts. The play presents a complex portrait of self-injurious spite of heroic dimensions as it touches on issues of intense shame, feelings of helplessness and the refusal of forgiveness. Sophocles's protagonist, Philoctetes, is a man who, like some of our patients, refuses to be healed. He intends, through his continued sickness and misery, to exact revenge against those who mistreated him. These are recognizable clinical issues, playing roles in every psychoanalytic treatment, issues that may assume a special importance in protracted, stalemated or aborted analyses. There are patients who damage the analyst by damaging the analysis they are in, a malevolent project often undertaken in revenge for wrongs suffered during childhood. This paper links Sophocles's drama to these vitally important clinical considerations through the discussion of a particular case.
Perversion in La mala educación [Bad education] (2004).
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Pentheus rather than Oedipus: on perversion, survival and analytic 'presencing'.
Following an introductory review of the main developments in the psychoanalytic thinking on perversion, the author focuses on her own understanding of perversion and its treatment, based on the psychoanalytic treatment of patients with severe sexual perversions. This paper uses the term 'autotomy' (borrowed from the field of biology) to describe perversion formation as an 'autotomous' defence solution involving massive dissociative splitting in the service of psychic survival within a violent, traumatic early childhood situation; thus, a compulsively enacted 'desire for ritualised trauma' ensues. The specific nature of the perverse scenario embodies the specific experiential core quality of the traumatic situation. It is an actual repetition in the present of the imprint of a past destructive experience which is pre-arranged and stage-managed; it thus encounters haunting scenes of dread or psychic annihilation while, at the same time, controlling, sanitising and disavowing them. Hence, the world of severe perversion is no longer oedipal, but rather the world of Pentheus, Euripides's most tragic hero--a world dominated by a mixture of a mother's madness, devourment, destruction and rituals of desire. According to this view, the (difficult) psychoanalytic treatment of perversion focuses on patient-analyst interconnectedness--brought about by the analyst's 'givenness to being present' or 'presencing'--at a deep, primary level of contact and impact (the emphasis being on the ontological dimension of experience). This evolving therapeutic entity creates and actualises a new, alternative experiential-emotional reality within the pervert's alienated world, eventually generating a change in the perverse essence. The author illustrate this approach with three clinical vignettes.
Perverse relationships: the perspective of the perpetrator.
The author examines the theme of perverse relationships within the couple, focusing on the question of men's maltreatment of their female partners, particularly in the psychological sense. Various aspects of the perpetrator's personality and relational style are described. The author takes as her starting point and discusses in depth the concepts of 'narcissistic perversion' (Racamier, 1992) and 'relational perversion' (Pandolfi, 1999), considered useful for understanding and identifying this type of pathology. She postulates that maltreating behaviour, in fact, originates from the encounter of particularly non-empathic relational styles which are typical of certain personalities (mainly, but not exclusively, of the narcissistic disorder) with 'perversity', that is, perversion, understood as a character trait. The author makes a distinction between 'relational perversion' and 'sado-masochistic relationship', and presents a clinical picture deriving from the analysis of a man who maltreats his companion, in order to shed light on the above-mentioned aspects, touching on some problems arising in the analysis of such patients. In conclusion, she considers some aspects of the experience of victims of maltreatment.
Why perversion?: 'False love' and the perverse pact.
In this paper, the author works with the awareness that perversion is a socially, historically and theologically loaded term, at the same time as it may be the latest frontier in psychoanalysis, both clinically, and in relation to contemporary art and culture which emphasize the perverse. Positioning itself against tendencies to deny the existence of a category of 'perversion' or, inversely, to abuse it for the power that accrues from the act of diagnosing, she also points to other liabilities in the history of the treatment of this term, such as the narrowing down of perversion to the exclusively sexual domain, or, alternatively, the overextension of it to polymorphously erotic practices that enhance sexual excitement. The paradoxes of perversion and the difficulties of distinguishing the perverse from the non-perverse are addressed. The case is also made that, in order to understand perversion, one must unlink it from the narrow notion of sexual practice and see what is involved on a deeper level--an approach initiated when psychoanalysis turned to perversion as a defense against psychotic anxieties, and began considering the necessary place of perversion in the transference--countertransference. Two features common to both sexual and non-sexual perverse relations are the seductive and bribing aspects of perversion, and its means-ends reversal. Perversion is a haven for the disguising of hatred and suspicion as excitement and (false) love. Displaced child and beating father, entitled child and seductive mother, are both prototypes of psychoanalytic reflection on parents who excite, deceive and corrupt their children and establish perverse pacts with them. The notion of the perverse pact is foregrounded in Alice's analysis, where first the resurrection and then the dismantling of such a pact were effected through various analytic means.
Simultaneous analysis of child and parent by the same analyst.
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Transvestism: new perspectives.
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Psychoanalytic constructions of female development and women's conflicts about achievement. Part I.
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Forced terminations.
Forced terminations are common clinical experiences and pose particular challenges and opportunities. They fall into four categories: mutually agreed upon, unilaterally forced by the patient, forced by realistic external circumstances, and unilaterally forced by the therapist. These differing situations are examined and compared, with attention directed to the use of reality as resistance, to the narcissistic injury in forced terminations, and to the potential transference-countertransference collusions to avoid powerful reactions to separation and loss. Problems with masochistic patients are considered opportunities for "bad endings." Technical considerations are discussed.
Internalized homophobia and the negative therapeutic reaction.
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Cross-cultural dimensions of sadomasochism in the psychoanalytic situation.
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