Australian and New Zealand Journal of Psychiatry (1975) 9
. 31
PSYCHOTHERAPY AND THE IATROGENIC ‘LOVE AFFAIR’* by GEORGE L. CHRISTIE
SYNOPSIS After giving an htroductory outline of the phenomenology and theoretical q e c t s of the concept ‘love affair‘, the author proceeds to review a number of symptomatic love affairs arising in the lives of a series of female patients during the couw of analytically oriented psychotherapy. The materid is presented in its general aspects and in the form of one detailed case hjstmy. Zn subsequent d i s c d o n the author attempt8 to txplain the genesis of theae love affairs in terms of phase-specific conflicts in the patient and certain iatrogenic aspects o€ the thmpy. INTRODUCTION A love affair, developing in the life of a patient during psychotherapy, may be a sign of growth i.e. of an increasing capacity for human closeness. However it may be something quite different from this, viz. a piece of symptomatic behaviour, directly related to the psychotherapy, and representing a defensive consequence of transference feelings (e.g. a flight from the therapist to a new object). The psychotherapist may fail to discern the true nature of his patient’s love experience. A possessive therapist may wrongly attribute a patient’s new relationship to some sort of acting-out when it represents a healthy and timely separation from him. On the other hand he may mistakenly acknowledge a new relationship as a step towards maturity through failing to perceive its regressive origins. Either way the patient can be disadvantaged, sometimes seriously. My own experience suggests that some symptomatic love affairs need not have happened, or need not to have developed so fully. Their iatrogenic origins therefore warrant careful attention. A symptomatic love affair can develop during any form of psychotherapy which tends to evoke strong infantile transference feelings, particularly where, for one reason or another, the therapist is unable to handle or interpret these feelings effectively, and
*Presented at the 1l t h Annual Congress, Australian and New Zealand College of Psychiatrists, Perth, October 1974.
especially where they are not properly understood or even recognised by him. The potential force of these feelings is considerable, as shown by the fact that occasionally love affairs actually develop between the patient and the therapist himself (be he psychiatrist, general practitioner, marriage guidance counsellor or whatever), particularly where the therapist is inexperienced, poorly trained or characterologically unsuited to hi? work (Voth 1972). This paper is not concerned with these disasters however, but rather with certain symptomatic love @airs that can develop outside the consulting-room.
THE CONCEPT ‘LOVE-AFFAIR’ A ’love affair’ can be defined as a more or less temporary passionate attachment between two people, arising when an irresistible feeling of attraction in one evokes a complementary response in the other. The psychological functioning of the two individuals involved can vary widely between so-called normal (tender) and pathological (infatuated) extremes (Christie 1969, 1972). Despite a remarkable heightening of physical and psychological well-being, the state of being ‘in love’ does not represent a wholly adult genital level of functioning by any means. hlany writers e.g. Freud (1930), Suttie (1935), Fenichel (1946) and B a h t ( 1965), have emphasised the extreme regressive component in romantic love, and the archaic origin of its tenderness in the symbiosis of early infantmother relating. Freud saw the tenderness of the !over as representing at least a partial return to the period before discrimination of self from mother is established. If the regressive nature of romantic love was better understood (i.e in terms of more phase-specific regression) we might then have the key to explaining two other features of interest viz. its affective and narcissistic aspects. The mood of the person “in love” has a distinctly manic element. This may be missed by the observer because it doesn’t seem, and is not necessarily, inappropriate. The pink cheek, quickened step, elation and new-found initiative of the lover are proverbial, but empathy for others may be lacking a n d judgment impaired to some extent. In fact
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PSYCHOTHERAPY AND
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THE
certain cyclothymic individuals ‘in love’ can pose a diagnostic problem for the clinician i.e. which came first, the elation-producing new relationship or a manic up-swing? In addition, genuine depressive feelings often colour an individual’s response to the vicissitudes of his love relationship (and he may be more prone to fall in-love when depressed). Being “in love” has also a markedly narcissistic component i.e. a tendency to live, as the song puts it “in a wonderful world of my own”. Feeling loved, a person can become .quite transformed in appearance. A woman appears more beautiful (cf. Narcissus), with heightened colour and a new softness and grace in her manner. She enjoys a greatly expanded capacity for aesthetic experience, e.g. in relation to music or the contemplation of nature. She has developed the cherished illusion of having found a partner able to give flesh and blood form to her inner ideal primary object (ultimately the ‘good‘ mother). There are some interesting points of comparison here with other narcissistic states. In reporting the analysis of a three year old schizophrenic boy Rodrigue (1955) describes the beauty, musical talents, graceful movements and moments of bliss of some secondarily autistic children. Klein ( 1946) attributes the origin of such narcissistic states to a retained relationship with an ideal inner object (all hostility being projected onto the external world). Similarly Mahler ( 1961) perceives secondarily autistic children as continuing, or regressing to, a symbiotic union with an internalised ‘good’ mother. Rodrigue sees the ultimate content of such a child’s inner world as “an ideal relationship with a beautiful, ever-lasting, ever-present breast” and asks whether the beauty of such children and their talent for music may not be determined by this. Music, he says . . . may be the medium of expression, the language of love with an ideal object”. Perhaps such considerations apply also to the narcissistic-idealistic aspects of being ‘in love’.
IATROGENIC ‘‘Lorn AFFAIR’’ THE CLINICAL MATERIAL This paper is based on a largely retrospective evaluation of thirteen love affairs occurring in the lives of eleven of my female patients during on-going analytically-oriented psychotherapy. I have applied the term “love affair” rather broadly here in order to cover experiences ranging from several passionate, fully sexual liaisons through various intermediate forms to one transient (unreturned) infatuation. The psychotherapies were all long-term, ranging from three to seven years, four of them still current, the frequency of sessions varying from twice a week to once a month. Seven of the eleven patients received exploratory hallucinogenic drug sessions at an earlier stage when I was interested in this technique. Leaving aside the presenting symptonaatology, the underlying personality structures of the eleven patients were as follows:- seven hysterical-narcissistic, one narcissistic, one schizoid, one borderline and one basically schizophrenic. Of the seven hystericalnarcissistic patients, three showed latent paranoid trends, two depressive trends, one an addictive trend and one an impulsive acting-out tendency.
In most cases the lovers had associative connections with the therapist. Three of the men were professional colleagues of mine (in two cases known by the patients to be on friendly terms with me), one was a patient’s G.P. ( a contemporary of mine), two were male acquaintances of exactly my age, one was a patient’s superior at work and was the producer of a play in which she took the female lead, and three were known by the women concerned to be psychotherapy patients of mine also. Of the remaining three, two were patients’ uncles (not blood-related) and one a cousin. I would like to single out two general features of interest from the clinical material:
‘I.
HOWis it then, with all these regressive features, that romantic love is so commonly found in the general population i.e. among non-psychotic people? How can falling in-love be a sign of a healthy capacity for human closeness? The answer seems to be that romantic love can serve a useful and adaptive purpose despite its infantile origins. It brings two people close enough together, in a beautiful, even if partly delusional experience, for various intimacy barriers (Balint, 1965) to be overcome. In this way a passionate bond is established, providing a setting in which the beginnings of real mutuality can take shape and grow into a more genuine and adult relationship. It is the failure of the initial passionate attachment to evolve in this way that characterises so many love affairs. Such failure appears more likely when the initial passionate attachment represents a symptomatic acting-out.
( 1 ) Of the eleven patients, nine were able to express relatively little in the way of strong feelings (warm or angry) towards me during their treatment. On the other hand all eleven patients showed evidence, clinically and/or on projective testing, of unconscious or denied aggression (often of primitive quality).
(2) With six of the love affairs the case histories strongly suggest that the onset of the affair was preceded by some experience of separation from the therapist. There was a similar (but less strong) suggestion in four cases. The persistence in a patient’s unconscious of such a connection (between love affair and separation from me) was revealed in the following example Case 1 A married woman developed an intense infatuation for a married cousin during the course of long-term psychotherapy. Their love aff5ir lasted about two years and caused many problems for both families.
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GEQRGE L. CHRISTIE Eventually their passion subsided and they agreed to cease contact with each other. Some months later I arranged to go overseas for a short period. In the last days before I left, my patient became very anxious. However her conscious concern was with a transient revival of infatuation feelings for her cousin, rather than with any reaction to my departure (the real cause of her anxiety). The infatuation feelings soon disappeared again. Although most of the patients in this series appear to have benefited from their psychotherapy overall, the outcome of the love affairs themselves has been very variable. Four affairs have resulted in the patients breaking off treatment, although one has returned recently. Three of the affairs have been obviously destructive to one or both parties, and several have been precarious in terms of their potential destructiveness. On the other hand two affairs seemed to have helped patients break up unsatisfactory marriages. Two patients have actually married their lovers (both patients of mine also), with a happy outcome for both parties in one case, and a very precarious adjustment in the other. I would now like to describe one typical case in some detail. case 2
Mrs. A., a twenty-seven year old married woman with three children, consulted me with symptoms of depression and relative frigidity. She saw as her central problem in life an inability to communicate with her busy, professional husband. She presented an hysterical-narcissistic personality picture with obvious dependency, some lability of emotion and a rather naive “Southern Belle” attitude. Psychological testing suggested also a denial of hostile feelings, particularly towards men, and a denial of deeper, more disturbed depressive feelings. On the positive side she appeared intelligent, sensitive and rather creative, with some genuine desire for closer relationships with people, including her husband. The husband was a cool, reserved man with a dislike for strong emotions, who tended to withdraw from her dependency and emotionality. Mrs. A. felt she had made a wrong choice of husband, attributing this mistake to an impulsive response to the initial warm reception accorded her by his family. When Mrs. A. was eight, her mother died from peritonitis. She had never felt close to her father, and subsequently spent many years in boardingschool. I began seeing Mrs. A. in an exploratory psychotherapy that extended over three years, and involved forty-three sessions, six in the presence of her husband and nine aided by the hallucinogen psilocibin. Her progress was very slow until on one occasion the drug released a warm, idealised recall of blissful communication with her mother, prior to the latter’s death. She remembered holding her mother’s hand
33
and listening to her voice, in sunny, flowered settings. The treatments gradually resulted in Mrs. A. feeling more alive and hopeful generally, but more frustrated and pessimistic about her marriage. Eventually Mrs. A. felt well enough to continue without treatment and ceased attending for a few months. During this period however she wrote me two letters and telephoned a few times without an appointment being made. She occasionally referred to anxiety and to a need to talk things over with somebody, perhaps me. In both letters she wrote of her deepening conviction that she could not stay living with her husband, adding in one “I long for a warm, spontaneous relationship with an alive, enthusiastic kind of man and I find myself searching for him now”. One day she came to see me again, and immediately afterwards began an alive and sexually satisfying affair with a single creative man friend of my age (i.e. seventeen years older than Mrs. A.). Subsequently she wrote and informed me @f the love affair as if in passing, describing her lover as a spontaneous, enthusiastic and generous man. She added a fear however that this new relationship might cause her to forgo my respect. She said she valued her ‘‘unique relationship” with me, and felt that it included “real communkation”. However, in all her interviews and letters this ‘real communication’ had never included any direct revelation of loving feelings towards me, nor, on the other hand, any sign of resentment or criticism e.g. in relation to breaks in treatment or other frustrations. In fact it was two years before I learned from the patient that she began her affair by going straight from my consulting-room to the man’s apartment, feeling that she “couldn’t get enough from psychotherapy”. After some months of new life and enthusiasm Mrs. A. experienced a mild recurrence of depression, related to a feeling that she was seeing too much of her lover and becoming too attached to him. Soon afterwards I gave her a final psilocibin injection, and the treatment immediately restored her feelings of enthusiasm and vigour. Six days later she wrote “the treatment seems to rejuvenate me, all my senses seem resharpened - one sees life afresh and it looks so good”. She went on to write how she had never been able to let her father know the intensity of the love she had felt for her mother. She spoke also of progressively separating off from her husband, and reported two dreams that involved needing to kill a man in order to be free. Mrs. A. ceased coming for six months, and then resumed what has become a largely supportive psychotherapy. During the last two years she has been adamant in her pursuit of a lasting separation from her husband. She has had occasional episodes of moderately severe depression which have responded well to nardil (apart from mild hypo-manic reactions to the drug). One such depressive episode developed in early 1974 after she had lost contact k i t h me for several months.
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IATROGENIC “LOVE AFFAIR”
Mrs. A. lives with her three children, and now has two men friends. One is the original lover, but the relationship, although still pleasurable, is today rather muted. The other friend (a married man) is a more serious type “who is always concerned about such things as time”. Mrs. A. is coping with her responsibility, but remains subdued, unfulfilled emotionally, and uncertain about her future. She sees me fortnightly but shows resistance to further insight therapy. [n many responses (e.g. her psilocibin-released fantasy and her feeling of not being able to get enough from the psychotherapy session) this woman demonstrates a continuing yearning for a maternal type of loving, with, I believe, much latent ambivalence towards her objects.
Dmssion Was Mrs. A’s love affair the natural result of an increasing capacity for personal and sexual intimacy, or was it, at least in part, a symptomatic consequence of her psychiatric disorder and its treatment? I believe that her case history (and those of the other patients) suggests the latter. If this is so, why does such a love affair develop during psychotherapy? The answers to this question must lie in the personality and phase-specific conflicts of the patient, in the nature and competence of the psychotherapy, and perhaps also in the attitudes and behaviour of the therapist. In pondering upon the genesis of these love affairs, 1 concluded initially that a patient like Mrs. A. turns from her therapist to a surrogate figure in the frustration of realising that her revived and intensifying needs will not be gratified directly in the treatment situation. I felt also that the turning away might be a means of taking revenge upon the therapist or of fleeing from a dangerous transference situation to a safer one. Since starting to write this paper. however, I have come upon an article by Ping-nie Pao* (1973) which appears to throw new light upon the subject and open a new area for interpretation, at least for some cases. Pao described a phenomenon, encountered in the treatment of hospitalised schizophrenic and severe border-line cases, where the patient shows a “defensive flight 10 a new object” as a Consequence of experiencing severe separation panic and associated intense ambivalent feelings towards the therapist. As a rule these feelings are denied or obliterated by the patient from his or her awareness so that unless carefully scrutiiiised, the defensive aspect of the flight may escape the notice of even a competent therapist. Such flight may occur in patients from any diagnostic category, at any phase of treatment. *Director of Psychotherapy, Chestnut Lodge, Rockville, Maryland.
.
According to Pao “. . . . . a neurotic may even make a success of it”. It is the denied ambivalent feelings that provoke flight. Pao sees the pathogenic intra-psychic conflict revived here as originating in Mahler’s (1968) phase of separation-individuation (late first and second year of life) when the infant is emerging from a stare of symbiosis with the mother. Like splitting (into ’good’ and ‘bad’ objects) the flight from a ‘bad‘ to a ‘good’ object is a phase-specific phenomenon. It requires the attainment of a certain maturational level of motor development and a history of encouragement from other adults in the infant’s environment. And, again like splitting, such flight may be adopted by the ego as a defensive measure. Let us look a t Mrs. A’s case history again in the light of these suggestions. An early productive psychotherapy (aided by psilocibin) led to the reawakening of loving memories of the mother and to establishment of a positive transference to the good (maternal) therapist. Eventually Mrs. A. was able to separate off from the therapist and ceased attending. However this was followed by separation anxiety and subsequent disappointment in the therapist (for not seeing her in response to her letters and telephone calls). Any ambivalent response to him was immediately denied, and as a consequence there arose in her mind a defensive splitting into a ‘bad’ object (the therapist) and a ‘good’ object (an idealised creative man of identical age). A defensive flight from the ‘bad’ to the ‘good’ object ensued (a literal and direct flight from the therapist’s consulting-room to the apartment of the other man) and a love affair sprang into life. It is of interest that her later acquisition of a second man-friend produced a trace of the earlier splitting in that she began to alternate between her generous lover and a married man, who, like psychotherapists, was “always concerned about such things as time”. While the primary function of defensive flight is protection against the experience of intense ambivalent conflict, Pao points out that other unconscious motives may be added. The flight may express feelings of hatred, of desire for revenge. It may represent an active effort of rejecting, an active effort to elicit in others the response of claiming, an active effort to spare the hatred object from one’s own destructive impulses, a regressive establishment of a sense of well-being or various combinations of these motives. The management of such flight depends upon its recognition and effective interpretation. Once a love affair has become established the transference feelings are lost to therapy, at least temporarily, and any interpretations given usually receive a neutral response. However, according to Pao, the patient usually gives enough notice of impending flight to warn an alert therapist (cf. “I long for a warm, spontaneous relationship with an alive, enthusiastic kind of man and I find myself searching for him
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GEORGE L. CHRISTIE now”). The therapist’s failure (consciously or not) to perceive or respond to the patient’s warning may be another story, of course, requiring its own explanation. Pao suggests an appropriate interpretation for the therapist to use in response to the patient’s warning of an impending flight “. . . . Because of your anxiety over separation or loss, you may feel you are being abandoned by me, that there is a lessening of my interest in you or a removing of my protection and approving eye on you. You seek a new relationship to fill the void and to defend against the growing feeling of hurt and anger towards me for exposing you to this anxiety”. I would also like to raise two obvious points of criticism in relation to the treatment of these eleven patients. Although there may still be limited indications for the hallucinogens (e.g. in the treatment of some traumatic neuroses) I believe no longer in their more general application as exploratory aids in psychotherapy. The dissolving of ego defences, and the facilitating (and intensifying) of infantile transference feelings, go far beyond that of the intravenous barbiturates and stimulant drugs, and the resulting regressive pull of the whole treatment situation can far exceed its therapeutic efficacy, at least in my hands. The question must also be raised as to whether a once per week type of psychotherapy provides for any adequate consideration of the therapist-patient relationship, particularly during periods of (treatment-evoked) regression. If infantile needs and demands emerge openly in the relationship there will be insufficient time or continuity of sessions for the situation to be handled effectively by the therapist. When the patient becomes demanding ( e g telephones excessively), the harassed therapist may tune out from the patient’s anxiety, fall back upon judgmental use of labels like ‘infantile’, ‘hysterical’, and ‘manipulative’, and conclude that the patient is ‘unsuitable for insight therapy’. However, in my experience, these are not the patients likely to develop symptomatic love affairs. The latter are the ones who find it hard to bring out feelings and fantasies about the therapist, i.e. the more defensive or inhibited patients, who often choose in sessions to dwell upon current outside happenings or about events in the past. Insufficient exposure to these patients can cause the therapist to miss or underestimate transference developments and the effect upon his patients of his absences and neglects. The patient’s transference feelings can gradually increase to anxiety-provoking levels and then be acted out with external surrogate figures as already described. The uninformed therapist may even misread this as representing real growth.
.
.
PREVENTION AND MANAGEMENT Symptomatic love affairs can develop during any psychotherapy. However, we have seen that they are
35
facilitated by certain conflicts in the patient, and by certain developments in the therapy itself. My review of these eleven cases underlines the prophylactic importance of choosing a psychotherapy tailored to the needs and personality of the patient, and to the training, skills and limitations of the therapist. Malan (1963) has shown us how much can be achieved even in a limited time by the analyticallyoriented psychotherapist, as long as there is a clarity of goals, an early focussing upon specific transference issues, and an opportunity for the patient to anticipate termination of treatment, and work through feelings associated with this inevitable separation. Such treatment, of course, requires patients to have suitable motivation and sufficient ego strength. It also requires an adequately trained therapist who has enough time available, not only for the patient, but also for reflection upon the progress of treatment. As a symptomatic love affair develops, the patient may seem to be immeasurably better e.g. a depressed patient may literally come alive. However, the psychotherapeutic relationship becomes correspondingly depleted, and any interpretation given to the patient lacks impact. The therapist may not be able to do much more than wait patiently, hoping his interpretations can eventually help to ensure that the affair is a learning experience, whatever its outcome. The risks of a symptomatic love affair are considerable, and there may be ‘the devil to pay’. However, it will usually run its course, leaving an often disadvantaged but perhaps wiser patient. It is important for the latter to know that the therapist remains available throughout, showing neither censure nor an illusion that the patient is cured. Sometimes the outcome of the affair may be more favourable. The new relationship can grow and deepen, to the benefit of patient and partner. Even where it doesn’t last, it may facilitate the demise of an unsatisfactory marriage. However, the fact of an occasional beneficial outcome is irrelevant to the main theme of this paper.
SUMMARY The author has reviewed a series of love affairs occurring in the lives of eleven patients during ongoing psychotherapy. He concludes that they are of iatrogenic origin. His material suggests that contributory factors can include the inhibited or defensive patient, the induction of more regression than can be handled satisfactorily in the therapy, some experience of separation from the therapist, a denial of resulting ambivalent feelings, and the therapist’s failure to perceive a patient’s warning of impending flight (Pao, 1973). A typical case is described in which the main thrust of the patient’s acting-out appears to be of preoedipal origin, involving a flight from the therapist (mother figure) to a surrogate figure, following a period of separation.
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According to Pao such a situation is due to the revival of an intra-psychic conflict characteristic of a phase (late first or second year) where splitting into bad and good (or ideal) objects, and flight from one to the other, are phase-specific defensive adaptations to threatening ambivalent feelings.
REFERENCES B a h t , M. (1965). Primary L o v e and Psychoanalytic Technique. Tavistock Publications, London. Christie, G. L. (1969). Falling-in-love and infatuation. Australian and N e w Zealand Journal of Psychiatry, 3: 17. Christie, G. L. (1972). The origins of falling-in-love and infatuation. American Journal of Psycho+ therapy, 2 6 244. Fenichel, 0. (1946). The Psychoanalytic Theory of Neurosis. Routledge and Kegan Paul, London. Freud, S. ( 1930). Civilisation and Its Discontents. Norton, New York. Klein, M. (1946). Notes on some schizoid mechanisms, in Developments in Psychoanalysis. Hogarth Press, London.
‘‘Lorn AFFAIR”
Mahler, M. S. (1961). On sadness and grief in infancy and childhood, in The Psychoanalytic Study of the Child. Vol. 16. International Universities Press inc., New York. Mahler, M. S. (1968). On Human Symbiosis and the Vicissitudes of Individuation. International Universities Press Inc., New York. Malan, D. H. (1963). A Study of Brief Psychotherapy. Social Science Paperbacks, London. Pao, P. N. (1973). On defensive flight to a new object. International Journal of Psychoanalytic Psychotherapy, 2: 230. Roderigue, E. (1955). The analysis of a three-yearold mute schizophrenic, in N e w Directions in Psychoanalysis. (ed. Klein, M.) Tavistock Publications, London. Suttie, J. D. (1935). The Origins of Love and Hate. Julian Press, New York. Voth, H. M. (1972). Love affair between doctor and patient. American Journal of Psychotherapy, 26: 394.
Reprint requests to: G. L. Christie 82 Toorak Road West South Yarra Victoria 3141
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PSYCHOTHERAPY AND THE IATROGENIC ‘LOVE AFFAIR’* by GEORGE L. CHRISTIE
SYNOPSIS After giving an htroductory outline of the phenomenology and theoretical q e c t s of the concept ‘love affair‘, the author proceeds to review a number of symptomatic love affairs arising in the lives of a series of female patients during the couw of analytically oriented psychotherapy. The materid is presented in its general aspects and in the form of one detailed case hjstmy. Zn subsequent d i s c d o n the author attempt8 to txplain the genesis of theae love affairs in terms of phase-specific conflicts in the patient and certain iatrogenic aspects o€ the thmpy. INTRODUCTION A love affair, developing in the life of a patient during psychotherapy, may be a sign of growth i.e. of an increasing capacity for human closeness. However it may be something quite different from this, viz. a piece of symptomatic behaviour, directly related to the psychotherapy, and representing a defensive consequence of transference feelings (e.g. a flight from the therapist to a new object). The psychotherapist may fail to discern the true nature of his patient’s love experience. A possessive therapist may wrongly attribute a patient’s new relationship to some sort of acting-out when it represents a healthy and timely separation from him. On the other hand he may mistakenly acknowledge a new relationship as a step towards maturity through failing to perceive its regressive origins. Either way the patient can be disadvantaged, sometimes seriously. My own experience suggests that some symptomatic love affairs need not have happened, or need not to have developed so fully. Their iatrogenic origins therefore warrant careful attention. A symptomatic love affair can develop during any form of psychotherapy which tends to evoke strong infantile transference feelings, particularly where, for one reason or another, the therapist is unable to handle or interpret these feelings effectively, and
*Presented at the 1l t h Annual Congress, Australian and New Zealand College of Psychiatrists, Perth, October 1974.
especially where they are not properly understood or even recognised by him. The potential force of these feelings is considerable, as shown by the fact that occasionally love affairs actually develop between the patient and the therapist himself (be he psychiatrist, general practitioner, marriage guidance counsellor or whatever), particularly where the therapist is inexperienced, poorly trained or characterologically unsuited to hi? work (Voth 1972). This paper is not concerned with these disasters however, but rather with certain symptomatic love @airs that can develop outside the consulting-room.
THE CONCEPT ‘LOVE-AFFAIR’ A ’love affair’ can be defined as a more or less temporary passionate attachment between two people, arising when an irresistible feeling of attraction in one evokes a complementary response in the other. The psychological functioning of the two individuals involved can vary widely between so-called normal (tender) and pathological (infatuated) extremes (Christie 1969, 1972). Despite a remarkable heightening of physical and psychological well-being, the state of being ‘in love’ does not represent a wholly adult genital level of functioning by any means. hlany writers e.g. Freud (1930), Suttie (1935), Fenichel (1946) and B a h t ( 1965), have emphasised the extreme regressive component in romantic love, and the archaic origin of its tenderness in the symbiosis of early infantmother relating. Freud saw the tenderness of the !over as representing at least a partial return to the period before discrimination of self from mother is established. If the regressive nature of romantic love was better understood (i.e in terms of more phase-specific regression) we might then have the key to explaining two other features of interest viz. its affective and narcissistic aspects. The mood of the person “in love” has a distinctly manic element. This may be missed by the observer because it doesn’t seem, and is not necessarily, inappropriate. The pink cheek, quickened step, elation and new-found initiative of the lover are proverbial, but empathy for others may be lacking a n d judgment impaired to some extent. In fact
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certain cyclothymic individuals ‘in love’ can pose a diagnostic problem for the clinician i.e. which came first, the elation-producing new relationship or a manic up-swing? In addition, genuine depressive feelings often colour an individual’s response to the vicissitudes of his love relationship (and he may be more prone to fall in-love when depressed). Being “in love” has also a markedly narcissistic component i.e. a tendency to live, as the song puts it “in a wonderful world of my own”. Feeling loved, a person can become .quite transformed in appearance. A woman appears more beautiful (cf. Narcissus), with heightened colour and a new softness and grace in her manner. She enjoys a greatly expanded capacity for aesthetic experience, e.g. in relation to music or the contemplation of nature. She has developed the cherished illusion of having found a partner able to give flesh and blood form to her inner ideal primary object (ultimately the ‘good‘ mother). There are some interesting points of comparison here with other narcissistic states. In reporting the analysis of a three year old schizophrenic boy Rodrigue (1955) describes the beauty, musical talents, graceful movements and moments of bliss of some secondarily autistic children. Klein ( 1946) attributes the origin of such narcissistic states to a retained relationship with an ideal inner object (all hostility being projected onto the external world). Similarly Mahler ( 1961) perceives secondarily autistic children as continuing, or regressing to, a symbiotic union with an internalised ‘good’ mother. Rodrigue sees the ultimate content of such a child’s inner world as “an ideal relationship with a beautiful, ever-lasting, ever-present breast” and asks whether the beauty of such children and their talent for music may not be determined by this. Music, he says . . . may be the medium of expression, the language of love with an ideal object”. Perhaps such considerations apply also to the narcissistic-idealistic aspects of being ‘in love’.
IATROGENIC ‘‘Lorn AFFAIR’’ THE CLINICAL MATERIAL This paper is based on a largely retrospective evaluation of thirteen love affairs occurring in the lives of eleven of my female patients during on-going analytically-oriented psychotherapy. I have applied the term “love affair” rather broadly here in order to cover experiences ranging from several passionate, fully sexual liaisons through various intermediate forms to one transient (unreturned) infatuation. The psychotherapies were all long-term, ranging from three to seven years, four of them still current, the frequency of sessions varying from twice a week to once a month. Seven of the eleven patients received exploratory hallucinogenic drug sessions at an earlier stage when I was interested in this technique. Leaving aside the presenting symptonaatology, the underlying personality structures of the eleven patients were as follows:- seven hysterical-narcissistic, one narcissistic, one schizoid, one borderline and one basically schizophrenic. Of the seven hystericalnarcissistic patients, three showed latent paranoid trends, two depressive trends, one an addictive trend and one an impulsive acting-out tendency.
In most cases the lovers had associative connections with the therapist. Three of the men were professional colleagues of mine (in two cases known by the patients to be on friendly terms with me), one was a patient’s G.P. ( a contemporary of mine), two were male acquaintances of exactly my age, one was a patient’s superior at work and was the producer of a play in which she took the female lead, and three were known by the women concerned to be psychotherapy patients of mine also. Of the remaining three, two were patients’ uncles (not blood-related) and one a cousin. I would like to single out two general features of interest from the clinical material:
‘I.
HOWis it then, with all these regressive features, that romantic love is so commonly found in the general population i.e. among non-psychotic people? How can falling in-love be a sign of a healthy capacity for human closeness? The answer seems to be that romantic love can serve a useful and adaptive purpose despite its infantile origins. It brings two people close enough together, in a beautiful, even if partly delusional experience, for various intimacy barriers (Balint, 1965) to be overcome. In this way a passionate bond is established, providing a setting in which the beginnings of real mutuality can take shape and grow into a more genuine and adult relationship. It is the failure of the initial passionate attachment to evolve in this way that characterises so many love affairs. Such failure appears more likely when the initial passionate attachment represents a symptomatic acting-out.
( 1 ) Of the eleven patients, nine were able to express relatively little in the way of strong feelings (warm or angry) towards me during their treatment. On the other hand all eleven patients showed evidence, clinically and/or on projective testing, of unconscious or denied aggression (often of primitive quality).
(2) With six of the love affairs the case histories strongly suggest that the onset of the affair was preceded by some experience of separation from the therapist. There was a similar (but less strong) suggestion in four cases. The persistence in a patient’s unconscious of such a connection (between love affair and separation from me) was revealed in the following example Case 1 A married woman developed an intense infatuation for a married cousin during the course of long-term psychotherapy. Their love aff5ir lasted about two years and caused many problems for both families.
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GEQRGE L. CHRISTIE Eventually their passion subsided and they agreed to cease contact with each other. Some months later I arranged to go overseas for a short period. In the last days before I left, my patient became very anxious. However her conscious concern was with a transient revival of infatuation feelings for her cousin, rather than with any reaction to my departure (the real cause of her anxiety). The infatuation feelings soon disappeared again. Although most of the patients in this series appear to have benefited from their psychotherapy overall, the outcome of the love affairs themselves has been very variable. Four affairs have resulted in the patients breaking off treatment, although one has returned recently. Three of the affairs have been obviously destructive to one or both parties, and several have been precarious in terms of their potential destructiveness. On the other hand two affairs seemed to have helped patients break up unsatisfactory marriages. Two patients have actually married their lovers (both patients of mine also), with a happy outcome for both parties in one case, and a very precarious adjustment in the other. I would now like to describe one typical case in some detail. case 2
Mrs. A., a twenty-seven year old married woman with three children, consulted me with symptoms of depression and relative frigidity. She saw as her central problem in life an inability to communicate with her busy, professional husband. She presented an hysterical-narcissistic personality picture with obvious dependency, some lability of emotion and a rather naive “Southern Belle” attitude. Psychological testing suggested also a denial of hostile feelings, particularly towards men, and a denial of deeper, more disturbed depressive feelings. On the positive side she appeared intelligent, sensitive and rather creative, with some genuine desire for closer relationships with people, including her husband. The husband was a cool, reserved man with a dislike for strong emotions, who tended to withdraw from her dependency and emotionality. Mrs. A. felt she had made a wrong choice of husband, attributing this mistake to an impulsive response to the initial warm reception accorded her by his family. When Mrs. A. was eight, her mother died from peritonitis. She had never felt close to her father, and subsequently spent many years in boardingschool. I began seeing Mrs. A. in an exploratory psychotherapy that extended over three years, and involved forty-three sessions, six in the presence of her husband and nine aided by the hallucinogen psilocibin. Her progress was very slow until on one occasion the drug released a warm, idealised recall of blissful communication with her mother, prior to the latter’s death. She remembered holding her mother’s hand
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and listening to her voice, in sunny, flowered settings. The treatments gradually resulted in Mrs. A. feeling more alive and hopeful generally, but more frustrated and pessimistic about her marriage. Eventually Mrs. A. felt well enough to continue without treatment and ceased attending for a few months. During this period however she wrote me two letters and telephoned a few times without an appointment being made. She occasionally referred to anxiety and to a need to talk things over with somebody, perhaps me. In both letters she wrote of her deepening conviction that she could not stay living with her husband, adding in one “I long for a warm, spontaneous relationship with an alive, enthusiastic kind of man and I find myself searching for him now”. One day she came to see me again, and immediately afterwards began an alive and sexually satisfying affair with a single creative man friend of my age (i.e. seventeen years older than Mrs. A.). Subsequently she wrote and informed me @f the love affair as if in passing, describing her lover as a spontaneous, enthusiastic and generous man. She added a fear however that this new relationship might cause her to forgo my respect. She said she valued her ‘‘unique relationship” with me, and felt that it included “real communkation”. However, in all her interviews and letters this ‘real communication’ had never included any direct revelation of loving feelings towards me, nor, on the other hand, any sign of resentment or criticism e.g. in relation to breaks in treatment or other frustrations. In fact it was two years before I learned from the patient that she began her affair by going straight from my consulting-room to the man’s apartment, feeling that she “couldn’t get enough from psychotherapy”. After some months of new life and enthusiasm Mrs. A. experienced a mild recurrence of depression, related to a feeling that she was seeing too much of her lover and becoming too attached to him. Soon afterwards I gave her a final psilocibin injection, and the treatment immediately restored her feelings of enthusiasm and vigour. Six days later she wrote “the treatment seems to rejuvenate me, all my senses seem resharpened - one sees life afresh and it looks so good”. She went on to write how she had never been able to let her father know the intensity of the love she had felt for her mother. She spoke also of progressively separating off from her husband, and reported two dreams that involved needing to kill a man in order to be free. Mrs. A. ceased coming for six months, and then resumed what has become a largely supportive psychotherapy. During the last two years she has been adamant in her pursuit of a lasting separation from her husband. She has had occasional episodes of moderately severe depression which have responded well to nardil (apart from mild hypo-manic reactions to the drug). One such depressive episode developed in early 1974 after she had lost contact k i t h me for several months.
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PSYCHOTHERAPY AND
THE
IATROGENIC “LOVE AFFAIR”
Mrs. A. lives with her three children, and now has two men friends. One is the original lover, but the relationship, although still pleasurable, is today rather muted. The other friend (a married man) is a more serious type “who is always concerned about such things as time”. Mrs. A. is coping with her responsibility, but remains subdued, unfulfilled emotionally, and uncertain about her future. She sees me fortnightly but shows resistance to further insight therapy. [n many responses (e.g. her psilocibin-released fantasy and her feeling of not being able to get enough from the psychotherapy session) this woman demonstrates a continuing yearning for a maternal type of loving, with, I believe, much latent ambivalence towards her objects.
Dmssion Was Mrs. A’s love affair the natural result of an increasing capacity for personal and sexual intimacy, or was it, at least in part, a symptomatic consequence of her psychiatric disorder and its treatment? I believe that her case history (and those of the other patients) suggests the latter. If this is so, why does such a love affair develop during psychotherapy? The answers to this question must lie in the personality and phase-specific conflicts of the patient, in the nature and competence of the psychotherapy, and perhaps also in the attitudes and behaviour of the therapist. In pondering upon the genesis of these love affairs, 1 concluded initially that a patient like Mrs. A. turns from her therapist to a surrogate figure in the frustration of realising that her revived and intensifying needs will not be gratified directly in the treatment situation. I felt also that the turning away might be a means of taking revenge upon the therapist or of fleeing from a dangerous transference situation to a safer one. Since starting to write this paper. however, I have come upon an article by Ping-nie Pao* (1973) which appears to throw new light upon the subject and open a new area for interpretation, at least for some cases. Pao described a phenomenon, encountered in the treatment of hospitalised schizophrenic and severe border-line cases, where the patient shows a “defensive flight 10 a new object” as a Consequence of experiencing severe separation panic and associated intense ambivalent feelings towards the therapist. As a rule these feelings are denied or obliterated by the patient from his or her awareness so that unless carefully scrutiiiised, the defensive aspect of the flight may escape the notice of even a competent therapist. Such flight may occur in patients from any diagnostic category, at any phase of treatment. *Director of Psychotherapy, Chestnut Lodge, Rockville, Maryland.
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According to Pao “. . . . . a neurotic may even make a success of it”. It is the denied ambivalent feelings that provoke flight. Pao sees the pathogenic intra-psychic conflict revived here as originating in Mahler’s (1968) phase of separation-individuation (late first and second year of life) when the infant is emerging from a stare of symbiosis with the mother. Like splitting (into ’good’ and ‘bad’ objects) the flight from a ‘bad‘ to a ‘good’ object is a phase-specific phenomenon. It requires the attainment of a certain maturational level of motor development and a history of encouragement from other adults in the infant’s environment. And, again like splitting, such flight may be adopted by the ego as a defensive measure. Let us look a t Mrs. A’s case history again in the light of these suggestions. An early productive psychotherapy (aided by psilocibin) led to the reawakening of loving memories of the mother and to establishment of a positive transference to the good (maternal) therapist. Eventually Mrs. A. was able to separate off from the therapist and ceased attending. However this was followed by separation anxiety and subsequent disappointment in the therapist (for not seeing her in response to her letters and telephone calls). Any ambivalent response to him was immediately denied, and as a consequence there arose in her mind a defensive splitting into a ‘bad’ object (the therapist) and a ‘good’ object (an idealised creative man of identical age). A defensive flight from the ‘bad’ to the ‘good’ object ensued (a literal and direct flight from the therapist’s consulting-room to the apartment of the other man) and a love affair sprang into life. It is of interest that her later acquisition of a second man-friend produced a trace of the earlier splitting in that she began to alternate between her generous lover and a married man, who, like psychotherapists, was “always concerned about such things as time”. While the primary function of defensive flight is protection against the experience of intense ambivalent conflict, Pao points out that other unconscious motives may be added. The flight may express feelings of hatred, of desire for revenge. It may represent an active effort of rejecting, an active effort to elicit in others the response of claiming, an active effort to spare the hatred object from one’s own destructive impulses, a regressive establishment of a sense of well-being or various combinations of these motives. The management of such flight depends upon its recognition and effective interpretation. Once a love affair has become established the transference feelings are lost to therapy, at least temporarily, and any interpretations given usually receive a neutral response. However, according to Pao, the patient usually gives enough notice of impending flight to warn an alert therapist (cf. “I long for a warm, spontaneous relationship with an alive, enthusiastic kind of man and I find myself searching for him
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GEORGE L. CHRISTIE now”). The therapist’s failure (consciously or not) to perceive or respond to the patient’s warning may be another story, of course, requiring its own explanation. Pao suggests an appropriate interpretation for the therapist to use in response to the patient’s warning of an impending flight “. . . . Because of your anxiety over separation or loss, you may feel you are being abandoned by me, that there is a lessening of my interest in you or a removing of my protection and approving eye on you. You seek a new relationship to fill the void and to defend against the growing feeling of hurt and anger towards me for exposing you to this anxiety”. I would also like to raise two obvious points of criticism in relation to the treatment of these eleven patients. Although there may still be limited indications for the hallucinogens (e.g. in the treatment of some traumatic neuroses) I believe no longer in their more general application as exploratory aids in psychotherapy. The dissolving of ego defences, and the facilitating (and intensifying) of infantile transference feelings, go far beyond that of the intravenous barbiturates and stimulant drugs, and the resulting regressive pull of the whole treatment situation can far exceed its therapeutic efficacy, at least in my hands. The question must also be raised as to whether a once per week type of psychotherapy provides for any adequate consideration of the therapist-patient relationship, particularly during periods of (treatment-evoked) regression. If infantile needs and demands emerge openly in the relationship there will be insufficient time or continuity of sessions for the situation to be handled effectively by the therapist. When the patient becomes demanding ( e g telephones excessively), the harassed therapist may tune out from the patient’s anxiety, fall back upon judgmental use of labels like ‘infantile’, ‘hysterical’, and ‘manipulative’, and conclude that the patient is ‘unsuitable for insight therapy’. However, in my experience, these are not the patients likely to develop symptomatic love affairs. The latter are the ones who find it hard to bring out feelings and fantasies about the therapist, i.e. the more defensive or inhibited patients, who often choose in sessions to dwell upon current outside happenings or about events in the past. Insufficient exposure to these patients can cause the therapist to miss or underestimate transference developments and the effect upon his patients of his absences and neglects. The patient’s transference feelings can gradually increase to anxiety-provoking levels and then be acted out with external surrogate figures as already described. The uninformed therapist may even misread this as representing real growth.
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PREVENTION AND MANAGEMENT Symptomatic love affairs can develop during any psychotherapy. However, we have seen that they are
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facilitated by certain conflicts in the patient, and by certain developments in the therapy itself. My review of these eleven cases underlines the prophylactic importance of choosing a psychotherapy tailored to the needs and personality of the patient, and to the training, skills and limitations of the therapist. Malan (1963) has shown us how much can be achieved even in a limited time by the analyticallyoriented psychotherapist, as long as there is a clarity of goals, an early focussing upon specific transference issues, and an opportunity for the patient to anticipate termination of treatment, and work through feelings associated with this inevitable separation. Such treatment, of course, requires patients to have suitable motivation and sufficient ego strength. It also requires an adequately trained therapist who has enough time available, not only for the patient, but also for reflection upon the progress of treatment. As a symptomatic love affair develops, the patient may seem to be immeasurably better e.g. a depressed patient may literally come alive. However, the psychotherapeutic relationship becomes correspondingly depleted, and any interpretation given to the patient lacks impact. The therapist may not be able to do much more than wait patiently, hoping his interpretations can eventually help to ensure that the affair is a learning experience, whatever its outcome. The risks of a symptomatic love affair are considerable, and there may be ‘the devil to pay’. However, it will usually run its course, leaving an often disadvantaged but perhaps wiser patient. It is important for the latter to know that the therapist remains available throughout, showing neither censure nor an illusion that the patient is cured. Sometimes the outcome of the affair may be more favourable. The new relationship can grow and deepen, to the benefit of patient and partner. Even where it doesn’t last, it may facilitate the demise of an unsatisfactory marriage. However, the fact of an occasional beneficial outcome is irrelevant to the main theme of this paper.
SUMMARY The author has reviewed a series of love affairs occurring in the lives of eleven patients during ongoing psychotherapy. He concludes that they are of iatrogenic origin. His material suggests that contributory factors can include the inhibited or defensive patient, the induction of more regression than can be handled satisfactorily in the therapy, some experience of separation from the therapist, a denial of resulting ambivalent feelings, and the therapist’s failure to perceive a patient’s warning of impending flight (Pao, 1973). A typical case is described in which the main thrust of the patient’s acting-out appears to be of preoedipal origin, involving a flight from the therapist (mother figure) to a surrogate figure, following a period of separation.
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PSYCHOTHERAPY AND
THE IATROGENIC
According to Pao such a situation is due to the revival of an intra-psychic conflict characteristic of a phase (late first or second year) where splitting into bad and good (or ideal) objects, and flight from one to the other, are phase-specific defensive adaptations to threatening ambivalent feelings.
REFERENCES B a h t , M. (1965). Primary L o v e and Psychoanalytic Technique. Tavistock Publications, London. Christie, G. L. (1969). Falling-in-love and infatuation. Australian and N e w Zealand Journal of Psychiatry, 3: 17. Christie, G. L. (1972). The origins of falling-in-love and infatuation. American Journal of Psycho+ therapy, 2 6 244. Fenichel, 0. (1946). The Psychoanalytic Theory of Neurosis. Routledge and Kegan Paul, London. Freud, S. ( 1930). Civilisation and Its Discontents. Norton, New York. Klein, M. (1946). Notes on some schizoid mechanisms, in Developments in Psychoanalysis. Hogarth Press, London.
‘‘Lorn AFFAIR”
Mahler, M. S. (1961). On sadness and grief in infancy and childhood, in The Psychoanalytic Study of the Child. Vol. 16. International Universities Press inc., New York. Mahler, M. S. (1968). On Human Symbiosis and the Vicissitudes of Individuation. International Universities Press Inc., New York. Malan, D. H. (1963). A Study of Brief Psychotherapy. Social Science Paperbacks, London. Pao, P. N. (1973). On defensive flight to a new object. International Journal of Psychoanalytic Psychotherapy, 2: 230. Roderigue, E. (1955). The analysis of a three-yearold mute schizophrenic, in N e w Directions in Psychoanalysis. (ed. Klein, M.) Tavistock Publications, London. Suttie, J. D. (1935). The Origins of Love and Hate. Julian Press, New York. Voth, H. M. (1972). Love affair between doctor and patient. American Journal of Psychotherapy, 26: 394.
Reprint requests to: G. L. Christie 82 Toorak Road West South Yarra Victoria 3141
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