Blurring Boundaries or Why Do We Refer to Sexual Misconduct With Patients as “Boundary Violation”

I argue for the notion that we reserve the term boundary for the psychic realm because the psychic boundaries of psychoanalysis are so fundamentally complex, dense, and intrinsically confusing that bringing in the realm of behavioral ethical violations is actually unnecessarily vague and mystifying. The notion of a psychological boundary as a term in psychoanalytic work is a fragile, metaphoric construction that allows us to explore fantasy, affect, symbols, and elements of shared and unique realities. Psychoanalysis hinges on a social compact by patients and analysts to open up otherwise forbidden territory offered through this metaphoric construction. Rather than conflate forensic vocabulary (“violation”) with a central psychic concept for conducting psychoanalytic work (“boundary”), I suggest that we refer to ethical misconduct in more straightforward conventional terms such as misconduct (behavioral referents) or with specific psychological understandings of the many determinants of this behavior that we have available to us as psychoanalysts.     

Psychology impaired?

This article comments on M.J. Layman and J.R. McNamara's (1997) article about remediation for ethics violations. The author addresses the practice of regarding ethical violation, and its subset, boundary violation, and its subset, sexual misconduct, as synonymous. When professional impairment (disability) is seen as equivalent to sexual misconduct, the resulting generalized confusion impedes much needed progress in critical areas. The profession awaits structured assistance from the American Psychological Association to clarify and provide leadership in policy development.     

Commentary on Steven H. Cooper’s Paper “Blurring Boundaries or Why Do We Refer to Sexual Misconduct With Patients as ‘Boundary Violation’”

In this commentary on Steven H. Cooper’s paper, the author acknowledges that the term boundary violation presents a vexing problem when we try to integrate it with the traditional use of the term boundary in psychoanalytic thought. He suggests that the two discourses represent two separate but somewhat related levels of discourse and that overlap occurs in some areas but not in others. While the use of “boundary violations” to describe ethical misconduct presents problems, the author suggests that it may be useful for some analysts who have experienced a collapse of analytic space and can no longer “play” in a symbolic realm. He also suggests that we may be stuck with the term because of the unconscious function it serves for the analytic community.     

Ethical breaches and deviations of method in psychoanalysis: A heuristic model for the differentiation of boundary transgressions in psychoanalytic work

The boundary concept has been central to discussions on ethics and psychoanalysis over the past few decades. The main distinction has been between less malignant boundary crossings and more harmful violations. More recently, the concept has been criticized as not discriminating between technique and ethics. The author argues that these problems are connected to the way the boundary concept is defined. He suggests that it is specified to indicate a delimitation of an analytic area of conduct. In an analogous manner, an area of ethical conduct is framed by a boundary between ethical and unethical actions in the treatment situation. The analytic area has a narrower limitation than ethics and a stricter articulation of its concept of attitude; not all unanalytic actions are unethical. This simple model of interpersonally specified boundaries allows us to discriminate between different kinds of transgression in analytic work. In addition to violations and crossings, a third instance is described denoting a transgression of the analytic but not the ethical boundary. These can be called boundary stretchings, and are either intended or unintended deviations of method. The slippery slope mechanism of ethical misconduct is an imminent risk if boundary stretchings are ignored and not subject to scrutiny and analysis.     

Different Strokes in Boundary Artistry: Commentary on Cooper’s “Blurring Boundaries or Why Do We Refer to Sexual Misconduct With Patients as ‘Boundary Violation’”

In this commentary, the useful idea of psychoanalytic process as boundary art is taken up, elaborated, and further conceptualized. Two registers of psychic experience are utilized: the mutual and asymmetric modes of relating inherent in and definitional of analytic process. In line with Steven H. Cooper’s ideas, the givenness of boundaries in the mutual realm constitute the psychic matter of self-other differentiation. In contrast, the asymmetrical register marks boundaries as asserted and intended to be actualized in behavior. The usefulness of “boundary violation” as an expression of a perversion of ethical commitments is construed as a justified and necessary phrase. Boundaries in the asymmetrical register, continually asserted, make play and flex in the mutual register possible and in this way form a dialectical relation. In concert with Cooper, these assertions reflect the power of boundaries to ‘allow us to get lost.’ Fallibilities in the ways theories can be coopted to erase (and thereby truncate) aspects of the psychoanalytic process are described as a misuse (violation?) of boundary art.     

Chilled to the bone: embodied countertransference and unspoken traumatic memories

Starting from a deeply challenging experience of early embodied countertransference in a first encounter with a new patient, the author explores the issues it raised. Such moments highlight projective identification as well as what Stone (2006) has described as ‘embodied resonance in the countertransference’. In these powerful experiences linear time and subject boundaries are altered, and this leads to central questions about analytic work. As well as discussing the uncanny experience at the very beginning of an analytic encounter and its challenges for the analytic field, the author considers ‘the time horizon of analytic process’ (Hogenson 2007 ), the relationship between ‘moments of complexity and analytic boundaries’ (Cambray 2011 ) and the role of mirror neurons in intersubjective experience.     

The innocence of sexuality

The author explores aspects of sexual experiencing as they emerge in the course of development, especially as structured between parents and children. Is a certain mode of "innocent" sexual relating an important outcome of the developmental process, and does this mode have a place in the analytic process? The author suggests that the restoration of a capacity for sexual experiencing that is relatively free of convoluted developmental legacies may represent an important achievement in analytic work; and that the analyst's participation in this process, using his or her own capacity for "innocent" sexual responsiveness, may be essential to this outcome.     

Using Criminalization and Due Process to Reduce Scientific Misconduct

The issue of how to best minimize scientific misconduct remains a controversial topic among bioethicists, professors, policymakers, and attorneys. This paper suggests that harsher criminal sanctions against misconduct, better protections for whistleblowers, and the creation of due process standards for misconduct investigations are urgently needed. Although the causes of misconduct and estimates of problem remain varied, the literature suggests that scientific misconduct—fraud, fabrication, and plagiarism of scientific research—continues to damage public health and trust in science. Providing stricter criminal statutes against misconduct is necessary to motivate whistleblowers and deter wrongdoers, and the provision of basic due process protections is necessary for ensuring a fair and balanced misconduct investigation.     

Heteronormativity,Disgust Sensitivity,and Hostile Attitudes toward Gay Men: Potential Mechanisms to Maintain Social Hierarchies

Within a social hierarchy based on sexual orientation, heteronormative ideology serves as a social force that maintains dominant group members’ status (e.g., heterosexual men). Disgust may be an emotional reaction to gay men’s violation of heteronormativity (i.e., same-sex sexual behavior) and motivate hostile attitudes toward gay men to promote interpersonal and intergroup boundaries. Based on this theoretical framework, we hypothesized that sexual disgust—compared to pathogen or moral disgust—would be most strongly associated with antigay hostility and would statistically mediate its relationship with heteronormativity. Heterosexual men in the United States (n?=?409) completed an online questionnaire assessing heteronormative ideology, disgust sensitivity, and hostile attitudes toward gay men. Results support the hypotheses and suggest that gay men’s sexual behavior is the most likely elicitor of disgust and antigay hostility, as opposed to a perceived pathogen threat or moral transgression. The findings indicate that heteronormative attitudes and sexual disgust are likely contributors to antigay hostility. Thus, intervention efforts should seek to improve tolerance of same-sex sexual behavior among heterosexual men, which may mitigate emotional reactions and hostile attitudes toward gay men.

     

Leaps of faith: Is forgiveness a useful concept?

Using detailed clinical vignettes, the author argues that, despite the current idealization of the concept of forgiveness, the term has no place in psychoanalytic work, and there are some hazards to giving it one. Clinically, the concept of forgiveness is seductive, implying that there should be a common outcome to a variety of injuries, stemming from different situations and calling for different solutions. Every instance of what we call forgiveness can be seen to serve a different defensive function. While the conscious experience of what is called forgiveness is sometimes confused with the unconscious process of reparation, the two can only be described at different levels of psychic life. Despite the fact that in ‘the unconscious’ there is no such thing as forgiveness, the term has an adhesive quality in our thinking that also blunts the analyst'’s appreciation of the aggressive components in the work. In a final vignette, the author illustrates an analytic outcome that has the appearance of forgiveness, but is best understood as the complex result of the everyday work of analysis.     

Boundary Violations and the Psychoanalytic Training System

A number of features of psychoanalytic training contribute to boundary violations and their sequelae. Intergenerational transmission of sexual misconduct is well-known and often operates unconsciously in the generation inheriting the legacy. Idealization and loyalty are frequent components of collusion and cover-up when a senior member of an institute is sexually involved with a patient. Other factors include the unique features of the termination of training analysis, the compartmentalization required in analytic work, and the ambivalent attitude towards autonomy and consultation.     

Speaking the unspeakable: institutional reactions to boundary violations by training analysts

The work of a COPE study group on boundary violations is summarized, with particular focus on the impact on institutes and societies of sexual misconduct by training analysts. Difficulties in evaluating such situations are discussed, and the dynamics of institutional avoidance explicated. In addition, psychodynamic themes that are commonly observed in analysts who engage in sexual boundary violations with their patients are elaborated. Finally, suggestions are made for managing, through existing mechanisms, instances of boundary violations by training analysts.     

What is “Good” Technique? How to Teach it? Personal Reflections on Psychoanalytic Training

There is an intense interest in the interactional process across the varying psychoanalytic schools of thought. The analytic relationship itself, in all of its complexity, is the vehicle for our work. These advances raise the question of what we mean by technique these days, a question that has implications for analytic training and supervision. In this paper, the author reflects back on his analytic training experience, specifically at how two of his supervisors regarded technique, how it was taught, and the various ways in which it was communicated. In looking back at these supervisory experiences, the author examines how these teaching analysts embodied some of what they had to teach. The author shows what was mutative across these training experiences in terms of what was needed in order to grow—what facilitated his own development as an analyst and contributed towards the cultivation of his own style.     

RUPTURES IN THE ANALYTIC SETTING AND DISTURBANCES IN THE TRANSFORMATIONAL FIELD OF DREAMS

This paper explores some implications of Bleger's (1967, 2013) concept of the analytic situation, which he views as comprising the analytic setting and the analytic process. The author discusses Bleger's idea of the analytic setting as the depositary for projected painful aspects in either the analyst or patient or both—affects that are then rendered as nonprocess. In contrast, the contents of the analytic process are subject to an incessant process of transformation (Green 2005). The author goes on to enumerate various components of the analytic setting: the nonhuman, object relational, and the analyst's “person” (including mental functioning). An extended clinical vignette is offered as an illustration.     

Permeability and Demarcation in the Psychoanalytic Process Functions of the Contact‐Barrier1

Introjection, identifi cation and projection are concepts that designate processes in which something is being put into or taken out of something else. These processes presuppose the overcoming of some form of separation between two entities. The permeability or impermeability of a fi ctive boundary between the representations of subject and object set the emotional tone of their coexistence. There are moments of complete diffusion, in which subject and object can no longer be differentiated, and moments of autistic enclosure in which the individual can no longer be reached at all. Permeability and demarcation result from the processing of stimuli carried out by the ‘contact‐barrier’, as an ego function. Stimuli of internal, libidinal or aggressive origin, as well as ‘im‐pressions’ of external origin, are classifi ed and processed with the aid of various kinds of factors arising from coagulated object‐relational experiences. Whereas for Freud the contact‐barrier regulates the quantity of energy and founds a topographical structure, Bion understands the contact‐barrier as a psychic function that simultaneously regulates boundary demarcation and making contact. In the psychoanalytic process, the contact‐barrier created by patient and analyst regulates the events in the transference and countertransference. An awareness of the struggle for contact and demarcation at the dynamic boundary representations that are constantly being recreated by both partners in the analytic process may be helpful in our clinical work. The author presents an examination of the ways in which patient and analyst make contact and demarcate the boundaries, which provides a better understanding of the dynamics of transference processes. He demonstrates this in relation to clinical material.     

On the immediacy of unconscious truth: understanding Betty Joseph's 'here and now' through comparison with alternative views of it outside of and within Kleinian thinking

Psychoanalysis emphasizes that in discovering psychic truth what is needed is not abstract or distant knowledge of this truth but rather an immediate encounter with it. In this paper the author examines the meaning of this immediacy through the study of Betty Joseph's notion of 'here and now,' which in recent years has been most directly associated with it. The author shows how Joseph's notion of 'here and now' continues a legacy beginning in Freud and taken up by Klein regarding the immediacy of unconscious truth that differs from other available analytic formulations of the term. To highlight the uniqueness of Joseph's contribution the author goes on to examine what distinguishes it within the kleinian framework. She does this in part through comparison with the clinical approach of Hanna Segal, whose focus on unconscious phantasy adheres to the same foundational legacy. The author points to the differences between Joseph and Segal and their significance, which have not been sufficiently elaborated in the analytic literature. She argues that viewing these differences within the context of a shared perspective on the role of unconscious truth in the analytic process and task enriches our understanding of the complexity of kleinian thinking and the meaning of truth in psychoanalysis. This understanding is also furthered by the recognition that many uses of the term 'here and now' in the analytic literature refer to something very different from what Joseph refers to and are based on a perspective that is fundamentally opposed to hers.     

The Write of Passage From Candidate to Analyst: The Experience of Writing Analytic Process

This article describes my experience of learning to write analytic process. It illustrates how the depth of understanding I achieved from learning to write transparently about analytic work was instrumental in the consolidation of my analytic training and my development of an analytic identity. Practicing analysis requires letting our minds function at multiple levels—integrating, synthesizing, free-associating, attending, and maintaining our own reverie—simultaneously. This is a large task for any analyst, much less a beginning analyst. Writing about this process necessitates not only understanding what has transpired in our offices with our patients but also developing the ability to explain that intimate and unique interpersonal dyad to our peers. Learning to do analytic work is not the same as learning to write about it; and writing about psychoanalytic process is very different from participating in it (Reiser, 2000). The goal of writing analytic process is not primarily to tell the story of the patient but to demonstrate our thinking, experience, and understanding as analysts. To do this requires both a depth of understanding of what we do and a mastery of analytic process.

While there may be different ways to synthesize and integrate our analytic training and to accomplish the significant task of progressing from candidate to analyst, learning to write analytic process was pivotal for me. It was a “rite of passage,” culminating in the development of an increased sense of identity, maturity, and confidence as an analyst.     

Are You Sure It Was with a Patient? What We Talk About When We Talk About Sexual Boundary Violations

Sexual boundary violations have occurred between psychoanalysts and their patients since the beginnings of our profession. Using results from an informal survey, this paper explores the effects of sexual breaches on a psychoanalytic training community from the point of view of a graduate. The author reviews some of the literature describing the great difficulty that analytic institutes have addressing these occurrences and suggests possible reasons for this difficulty.