The therapist’s love – Kerry Thomas-Anttila

March 23, 2009

Freud considered the therapist’s love to be one of the most, if not the most dangerous elements in psychotherapy, and that this area posed a direct threat to the evolution of his new science. To this end he wrote ‘Observations on Transference Love’ in 1915. It has been conjectured (Eickhoff, 1993) that the impetus to write this paper came from Freud’s concern over Jung’s relationship with his patient Sabina Spielrein, and also from Freud’s correspondence with Ferenczi about Ferenczi’s patient, Gizella (who Ferenczi later married), and also his patient Elma, Gizella’s daughter, with whom Ferenczi had a brief relationship, before marrying her mother.

In ‘Observations on Transference Love’ Freud stressed that the patient falling in love with the therapist is not due to the “charms of his own person” but is induced by the analytic situation. He believed that the passionate demand for love is largely the work of resistance and is an impediment to therapy. He advised on the danger of returning tender feelings, writing that the analyst’s control over himself may not be as great as he or she may imagine it to be. Further, he recommended treating the transference love as “unreal”, as a situation which has to be gone through in the treatment and traced back to its unconscious origins.

For many years there was little or no discussion in psychoanalysis about the therapist’s love; it was as if Freud had successfully closed off this area of inquiry and as if the only love to be considered was that of “transference love”, that is, the love of the patient for the therapist. Hirsch and Kessel (1985) also point out that Ferenczi’s early experiments with mutual analysis and his belief in the curative power of the analyst’s love to heal the patient, led almost to a phobia about mentioning anything about the therapist’s love (p. 74).

There is still much anxiety about using the word “love” in psychotherapy, in particular when applied to the love that a therapist might have for his or her patient or client. Coltart (2000) writes that the very use of the word ‘love’ in psychoanalysis is “often felt to be dangerous, or open to misconstruction” (p. 120). Bach (2006) writes that love in psychoanalysis is fraught with problems of transference and countertransference, the weight of social attitudes and collegial judgments, special ethical considerations, and even legal concerns (p. 126), and Lear (1990) notes that it is hard to take love seriously (p. 156) and that “love has become almost taboo within psychoanalysis” (p. 15).

Notwithstanding, with the increasing emphasis on relationality and intersubjectivity within the therapeutic relationship, there has been a movement towards considering the therapist’s love. In a review of mainly psychoanalytical literature (Thomas-Anttila, 2006) I explored the main themes that have presented themselves in this area. Questions I was interested in were, for example: Does the therapist love their patient or client in any way that is similar to what we might think of as love in other settings? Should the therapist love their patient? And whether or not they should, if they do then how might we describe that love? And what are the dangers and pitfalls in this area? This article highlights some of the findings of this research.

‘Parental Love’
Many writers have compared the therapist’s love to that of a parent. The qualities of this love include sympathetic understanding, affection, tenderness, empathy, patience, tolerance, punctuality, reliability, the ability to recognize the patient’s wishes as needs, containment, reverie, and so on. Ferenczi, Suttie, Balint, Winnicott are some of the theorists who write about the therapist’s love being akin to parental love. Much has been written about the value of the therapist’s “parental love”, particularly as it relates to the reparative nature of therapy, for example the importance of paying very close attention, that the therapist’s words and actions influence the production of hormones and neurotransmitters in the patient’s brain. Lewis, Amini and Lannon (2000) write that “psychotherapy alters the living brain” (p. 168) when the therapist is able to really listen and attune to the patient, that is, to provide a quasi-mothering function where the patient is nurtured emotionally and can rely and depend on the therapist. The longer a patient depends, they argue, the more stable they become, until they are able to gain their independence.

I think there are a few areas to watch out for in this area of parental love. One is that of course we are not the patient’s parent; the ability to observe the countertransference and to step out of it are intrinsic to the therapy process, and quite different to how we are as parents to our own children. The therapist’s love must be somehow detachable and more fluctuant than a parent’s.

Another area is to be aware of is that of hate. Love cannot be a sentimentalized thing devoid of its counterpart, hate, and in fact this is where Ferenczi became unstuck, as he realised some time down the track. In his keenness to be a perfect parent he realised that he was desperately fending off hate. He wrote of one patient “In actual fact and inwardly, therefore, I did hate the patient, in spite of all the friendliness I displayed” (Gabbard, 1997, p.8). He came to amend his original belief in the therapeutic benefit of disclosing love and affection to a belief in the therapeutic benefit of disclosing any emotion that the patient asks to have verified in one form or another.

Another area is that of the individual patient’s needs. Some patients may need more “parental love” than others. In any case, it is unlikely that even those who seem to need it the most will need it all the time, and it is unlikely that a one-size-fits-all approach is going to work.

The last area I would like to highlight here is that the maternal or paternal paradigm can act as a possible defense against exploring erotic feelings in the relationship. It is often easier to take the role of “therapist as mother” rather than offering oneself as an object of sexual cathexis. It has also been pointed out that the “feminization” of psychotherapy is leading to a philosophy whereby the only permissible relationship is a nurturing one between therapist and client. There may be such fear that sexual attraction will lead to exploitation that many therapists will retreat to the safety of the parental framework (Baur, 1997, p. 222). It seems likely that although some therapy relationships need to be of a parental nature, that not all therapy occurs in this paradigm.

Sexual Love and Eros
Sexual attraction and sexual feelings have long been considered problematic within the context of the therapy setting. Samuels (1999) points out that whereas analysts have different opinions on almost all aspects of analysis, there is almost unanimous agreement that sexual behaviour in analysis and therapy is damaging to the patient (p. 150). Erotic or sexual feelings towards the patient only began to be written about in an open way in the late 1950s. Since then the subject has been dealt with in various ways.

One theme that emerges is that there has been a growing acceptance and understanding of the therapist’s erotic responses and how to work with these in the therapy for the patient’s benefit. As well, there is discussion as to the extent to which the sexual or erotic love felt by the therapist towards the patient is countertransferential in nature or not. Mann (1997 & 1999) in particular is adept in arguing that it is important to go beyond the term ‘countertransference’ in describing the therapist’s feelings, and that erotic fantasies and desires can be well thought about and used to the patient’s advantage, rather than being an indicator of pathology in the therapist.

Another theme is that in the last decade, in particular, some writers are writing more about Eros than sex. These writers describe the paradoxical, passionate and creative aspects of Eros, as well as its transformative nature in the therapy. The benefits to the patient include opportunities to progress their development, to expand their emotional repertoire, and to have a therapy that is alive and meaningful. Thanatos and its interplay with Eros is explored. Eros becomes what Lear (1990) describes as the “basic natural force” (p.181) in the therapy. In this paradigm, notions of the ‘erotic transference’ being always a resistance to the therapy are reviewed; there is room for this transference also to be viewed as a desire for aliveness and meeting in the therapy. And so, although sexual enactments do not belong in the therapy situation and are harmful for the patient, many writers have noted that the repression and denial of the powerful forces of sexuality and Eros do not bode well either for a patient’s treatment. Sex and Eros are part of the therapy, and are part of the therapist’s love.

Love as a “Thing unto Itself”
Whereas traditionally, and still, interpretations have been viewed as the manifestation of the therapist’s love, there are also descriptions of other ways of viewing the therapist’s love and how it differs from love in other settings. Coltart (2000) writes a list of qualities which she feels are essential in order to practise as an analyst, and sums these up by saying that they can all be subsumed under the name of love. Coltart’s love includes ‘being with’ patients, and being on their side (as opposed to taking their side) in the search for truth and health. She writes of an attitude which makes the patient feel important in the relationship, and of the necessity of the analyst being both open to herself and unafraid to love (p. 90).

She describes many qualities and I think it is worthwhile to list at least some of them here: endurance, understanding, not using transference or countertransference destructively but only to create greater insight between the patient and ourselves, not exploiting his or her dependence on us emotionally, intellectually, sexually or financially, patience, single-minded attention to what is happening while at the same time allowing the inner flow of free-associative thoughts and images, a detachment rooted in thorough self-knowledge to experience and examine the countertransference and our own feelings, as well as scrutinizing the transference, sharply focusing, and scanning, complex involvement in feelings, and cool observation of them, close attention to the patient and to ourselves, distinguishing our own true feelings from subtle projections into us, communicating insight clearly, yet not imposing it, willing the best for our patients and ourselves, yet abandoning memory and desire, steering clear of being judgmental…sense of humour, toughness, courage, kindness, enjoyment (pp. 116-118). She describes the analyst’s love as being “the only trustworthy container” in which to feel the full spectrum of feelings, including hatred, rage and so on (p. 121), and adds that love is the “moral infrastructure of our job” (p. 122).

Worth mentioning also is the connection between loving the truth of psychic reality and the ‘object’ (patient) whose truth is to be discovered. Steingart (1995), in particular, emphasizes a love of the patient’s mind, and all that it produces; he calls this “scholarly analyst love” (p. 118). Bach (2006) goes further and describes a “falling in love” process when the therapist pays the type of attention that he calls the “moral equivalent of a prayer” (p. 133).

While there seem to have been changes in the way therapists practise, and some inroads made into a more widespread acceptance of the concept of the therapist’s love, at the same time, most writers are saying that we can compare the therapist’s love with the love of a parent, a lover, a sibling or friend, but in the end the asymmetrical nature of the therapy relationship means that it is none of these and the comparisons do not hold in a satisfying way. The most convincing contemporary description, for me, in reading about the therapist’s love, and the one that speaks to me the most in terms of my experience with patients, is Friedman’s (2005) concept of being immersed in and at the same time distant from the patient’s experience, and how this creates a feeling of love in the therapist which is particular to the analytic situation. This description seems to include the possibility of all the types of love being present in both patient and therapist, and reflects the asymmetrical nature of the enterprise, where the therapist participates fully, and observes at the same time, in order to ensure the safety of the patient. This also highlights that the therapist’s love may be necessary but it is not sufficient: it is not the therapist’s love itself which is curative, but rather how the therapist uses his or her love.

It is unlikely that this activity has in fact changed much since the beginnings of psychoanalysis. By its nature psychoanalysis has always been concerned with unconscious processes and the relationship has always been an intrinsic part of that. Many have pointed out that the so-called ‘blank-screen’ model was probably never practised by Freud himself, and Lewis, Amini and Lannon (2000) note that one of Freud’s strong points was never to take his own advice.


Bach, S. (2006). Getting from here to there: analytic love, analytic process. London: The Analytic Press.

Baur, S. (1997). The intimate hour: Love and sex in psychotherapy. New York: Houghton Mifflin.

Coltart, N (2000). Slouching towards Bethlehem. New York: Other Press.

Eickhoff, F-W. (1993). A rereading of Freud’s ‘Observations on transference love’. In E.S. Person, A. Hagelin & P. Fonagy (Eds.), On Freud’s ‘Observations on transference love’ (pp. 33-56). London: Yale University Press.

Freud, S. (1915). Further recommendations in the technique of psycho-analysis: observations on transference-love. In The standard edition of the complete psychological works of Sigmund Freud, 12, 157-171 (London: Hogarth Press, 1971).

Freud, S. (1893-1895). The psychotherapy of hysteria. In The standard edition of the complete psychological works of Sigmund Freud, 2, 255-305 (London: Hogarth Press, 1971).

Green, A. (2005). To love or not to love: Eros and Eris. In A. Green & G. Kohon (Eds.), Love and its vicissitudes (pp. 1-39). London: Routledge.

Friedman, L. (2005). Is there a special psychoanalytic love? Journal of the American Psychoanalytic Association, 53(2), 349-375.

Gabbard, G.O. (1997). Challenges in the analysis of adult patients with histories of childhood sexual abuse. Canadian Journal of Psychoanalysis, 5, 1-25.

Hirsch, I., & Kessel, P. (1985). Reflections on mature love and transference. Free Associations, 12, 60-83.

Lear, J. (1990). Love and its place in nature: A philosophical interpretation of Freudian psychoanalysis. London: Yale University Press.

Lewis, T., Amini, F., & Lannon, R. (2000). A general theory of love. New York: Vintage Books.

Mann, D. (1997). Psychotherapy: An erotic relationship. New York: Brunner-Routledge.

Mann, D. (Ed.). (1999). Erotic transference and countertransference: Clinical practice in psychotherapy. New York: Brunner-Routledge.

Natterson, J. M. (2003). Love in psychotherapy. Psychoanalytic Psychology, 20(3), 509-521.

Samuels, A. (1999). From sexual misconduct to social justice. In: D. Mann (Ed.), Erotic transference and countertransference: Clinical practice in psychotherapy (pp. 150-171). New York: Bruner-Routledge.

Shaw, D. (2003). On the therapeutic action of therapeutic love. Contemporary Psychoanalysis, 39(2), 251-278.

Steingart, I. (1995). A thing apart: love and reality in the therapeutic relationship. London: Jason Aronson.

Thomas-Anttila (2006). The Therapist’s Love. Unpublished dissertation, Master of Health Science, Auckland University of Technology, Auckland.

Weinstein, R.S. (1989). Should analysts love their patients? The resolution of transference resistance through countertransferential explorations. In J.F. Lasky & H.W. Silverman (Eds.). Love: Psychoanalytic perspectives (pp. 192-199). London: New York University Press.

Kerry Thomas-Anttila was born in Christchurch and has lived in Auckland for over twenty years. She completed a Master of Arts in German language and literature at Canterbury University in her early 20s and then went on to work in the public health sector in the employee relations/industrial relations area. After a psychotherapy training at AUT (Master of Health Science) Kerry now works as a psychotherapist in private practice in Parnell (website She is also in her final year of a three year clinical training with the Australasian Institute of Psychoanalytic Psychotherapy.


The role of relationship in the treatment of autism: perspectives from Relationship Development Intervention and psychotherapy – Colleen Emmens

November 13, 2008

During the time I was studying to become a psychotherapist, one of my grandsons was diagnosed with autism. For his parents, and extended family, from the moment of diagnosis, there began a long and difficult journey, first in grieving for the ‘lost’ child, then in researching how best to treat autism. At the time of my grandchild’s diagnosis, faced with a bewildering set of choices, some claiming to be proven effective, others with unproven promises of magical cures, his parents decided on the most accepted mainstream treatment of a behavioural approach. This is where skills are taught and problem behaviours are targeted.

From the start, these parents found this approach unhelpful in achieving what they wanted, which was to feel connected to their child. By chance my daughter came across a programme called “Relationship Development Intervention”(RDI) (Gutstein, 2000). She was excited by what she read, and although RDI was only about twelve years old at the time, its developmental, and relational approach made sense to her. For me, the RDI programme was intriguing, as it felt a match with the developmental theory and psychodynamic theory I was studying at the time. The opportunity came for me to go to Houston and study RDI, so I ended up studying and working with both psychotherapy and RDI alongside each other.

What I want to do here is to demonstrate why I believe psychodynamic theory has a lot to offer a clinical understanding of ASD. First I will introduce Steven Gutstein, as the founder of RDI. I will then describe an aetiology of autism, in the light of modern research, compared to a brief psychodynamic history, and followed by what autism is. I will summarize the work of Peter Hobson, a researcher and psychoanalyst at the Tavistock who has studied autism for 25 years, and whose studies are at the fore-front of autism research, and from where much of Gutstein’s clinical ideas spring from. Finally, I will compare this work with psychoanalytic theory.

Gutstein and his work
RDI is the result of the work of Dr.Steven Gutstein. He earned his Ph. D. in clinical psychology from Case Western Reserve University. From 1979 to 1987 he served as an Assistant Professor of Psychiatry and Pediatrics at Baylor College of Medicine and the University of Texas Medical School, as well as being director of Pediatric Psychology for Texas Children’s Hospital. He is a founder, and is currently the director of the Connection Center, which is the centre for RDI.

Gutstein describes a lonely childhood during his mother’s cancer and following her death (Gutstein, 2000). He describes feeling like the “eternal guest, tolerated and even welcomed, but always excluded from deep emotional connections” (Gutstein, 2000 p.xvi). In his academic life his passion has been in providing for others the experience of emotional connection. He believes in a capacity for emotional intimacy, no matter what the obstacle. In encountering autistic children he felt a kinship, where, “these individuals, for entirely different reasons were perpetual outsiders in the world of emotional encounters” (Gutstein, 2000 p.xvi).

What you might see
A three year old boy is sitting on the floor at Play-centre, engrossed in a game with train-tracks. He makes no attempt to play alongside or with other children, in fact he appears oblivious of their existence. If you sit beside him you find he is able to talk, but nothing in his talk is about communicating. Instead, he recites whole books, verbatim, to himself. If he hears a spoken word that reminds him of a book he knows, he switches to reciting that whole book. As a baby this child never pointed at things, or brought things to a caregiver to share. He never responded to his name, or used ‘checking’ behaviour with his Mother. He loved to be kissed, and would push his cheek into others’ faces and smile, but never with any shared eye contact. At two, he knew all his numbers, and appeared to know the value of these. He knew letters, and was able to read many logos, which he was obsessive about. This child, with his strange combination of talents and deficits, is autistic.

Aetiology of autism
The current overwhelming evidence is that autism is a global, neurological disorder that likely has multiple causes interacting in subtle and complex ways. (Gastgeb, Strauss, & Minshew, 2006; Mesibov, Adams, & Schopler, 2000; Minshew, Goldstein, & Siegel, 1997; Volkmar, 2000). Gutstein describes how a consensus has been reached by prominent researches, that autism is a “…neurologically based informaton processing disorder which impacts those on the spectrum in very specific ways, regardless of their IQ or language abilities” (Gutstein, 2006, p.2).Minshew, a professor of psychiatry and neurology at the University of Pittsburg, who has spent the last twenty years researching autism, and Marcel Just, (Carnege Mellon University), describe the disorder as a common, heritable neurodevelopmental condition with complex genetic architecture (Minshew & Williams, 2007; Just, et al, 2006) According to these, and other researchers, autism results when the brain fails to form the ability for flexible collaboration (called connectivity) between different brain centres. That is, separate parts of the brain can work perfectly in isolation. In a non-autistic person, it is this neuroconnectivity that provides the opportunity for flexible and original and integrated responses to the environment. The brains of ASD people don’t form collaborative relationships as they develop, instead, unconnected, discrete processing centres are strengthened. The natural course of autism is to get worse over time.

Historical Psychodynamic Aetiology
Leo Kanner, the child psychiatrist, who first described and named autism in 1943, originally believed that these children had an “…innate inability to form the usual, biologically provided affective contact with people” (Kanner, 1943, p.250). Donald Meltzer and his colleagues, who offered an intrapsychic view of infantile autistic psychosis, believed it to be related to depression in the mother, with the child not wanting to further burden their depressed mothers, and so dismantling their dependency aware egos (Meltzer, 1975). Alice Miller, who wrote about child abuse and its consequences, believed these children had experienced a history of suffering (Miller, 1991). Francis Tustin, a psychotherapist who spent a great deal of her life working with and studying autism, described autism as “…an early developmental deviation in the service of dealing with unmitigated terror” (Tustin, 1991, p.85). Tustin saw autism as a survival mechanism against a massive traumatic awareness of body separateness. In Contrast, Klein and Mahler saw autism as “constitutional”, or in-born. Melanie Klein described a little boy, Dick, who appears to have been autistic. She wrote that he had “…a complete and apparently constitutional incapacity of the ego to tolerate anxiety…” …” (cited in Hobson, 1990b, p.326). Later, Mahler describes how “the catalysing mothering agent for homeostasis, is inborn, constitutional, and probably hereditary…” (Mahler, 1968).

Kanner later changed his mind, to follow what became the prevailing view of autism, from the 1950s through to the 1970s, largely created by Bettelheim, where autism was thought to have been caused by mothers who were emotionally cold (Bettelheim, 1967). This view has not stood the test of scientific scrutiny. Susan Epstein, suggests that a psychoanalytic view of blaming mothers for causing this disorder in their children, although now seen as having been a cruel and unwarranted mistake, did at least accord some hope that it could be cured, and a fully functioning child could emerge (Epstein, 2000b). However, she suggests that “…historical efforts to explain and cure autism were not the psychoanalytic tradition’s finest hour” (Epstein, 2000a, p.746). She talks about the danger of attempting to fit phenomenology to theory.

In a paper written in 1990, Peter Hobson has reviewed some of the psychoanalytic approach’s ‘credentials’ in thinking about autism (Hobson, 1990b). His aim was to “challenge a more or less prevalent view that psychoanalytic approaches to autism are so fundamentally misconceived as to merit outright rejection” (Hobson, 1990b, p.324). In doing this, his hope was to examine what was of value in a psychoanalytic view.

I want to suggest that in fact Hobson is right, and psychoanalysis does have a major contribution to make in the understanding of, and clinical approach to autism, and that it is psychoanalytic understandings that hold the key.

Theory underpinning much of psychotherapy, would suggest that the kind of ‘wiring’ that is needed for a person to become able to communicate and operate in a complex and dynamic society, occurs in the earliest months and years between a child and their caregiver, beginning soon after birth. We can think about Winnicott’s statement , that there is no such thing as an infant…(1958, p.xxxvii). As a diagnosis of autism is usually not conclusive before a child is well into his/her second year, these neural pathways will already be impaired. For these children, the reasons that we form relationships, the enjoyment of connection and interacting, are not there. Autism is a disability that is defined by a deficit in the essence of relating, closeness and connection. RDI aims to bridge the gap between modern research and clinical practice, in order to ‘reconstruct’ the early foundations that are a prerequisite for success in real-life situations, such as having friends, a partner, and satisfying work. The pathway is a relational one, there is no way to ‘train’ or ‘drill’ children to have appropriate feelings and understanding of relationship. (Hadwin, Baron-Cohen, Howlin, & Hill, 1996; Hadwin, Baron-Cohen, Howlin, Hill, 1997).

What is Autism?
Autism is a pervasive developmental disorder, which shows qualitative impairments in social interactions, imaginative activity and both verbal and non-verbal communication skills. Children with autism tend to have limited interests and activities, and these are ritualised and stereotypic. They have a desire to maintain sameness in their routine and surroundings. Symptoms appear within the first three years of life (Kabat, Masi, & Segal, 2003).

According to Peter Hobson, autism is the “developmental outcome of profound disruption in the usual patterns of intersubjective coordination between the affected individual and others” (Hobson & Bishop, 2003, p.342). Hobson’s theory of intersubjectivity, suggests that without emotional involvement with other people, “…the whole of mental development is terribly compromised” (Hobson, 2002, p.183).

The fact that people with autism do not have these strong emotional pathways in no way distracts from their need for emotional and relational connection, they are still human beings, with the same universal needs (Gutstein & Sheely, 2002).

In their studies, Hobson and his colleagues describe autism as being like a photographic ‘negative’ of normal development, and see it as a chance to simultaneously study “how, in normal development, a young child’s engagement with other persons influences the development of their sense of self” (Hobson, Chidambi, Lee, & Meyer, 2006, p.vii). Hobson demonstrates with careful and detailed research, how children with autism do not have the same degree of shared, involved feeling with others. Someone else’s smile or delighted voice does not give them a feeling of warmth (Hobson, 2002, p.14). This manifests in their being less engaged with others, so that they are oblivious to what others might feel about their achievements, or of others’ attitudes towards them, or to a shared world. They are not so able to ‘read’ and therefore use, the facial expressions and body language of others to make sense of their own world. Although they are able to imitate others, Hobson and his colleagues have shown that they rarely imitate the style or tone of the actions of others, which suggests a reason for their relative lack of guilt or empathy. Hobson writes that “…this compromises their propensity to adopt and conceptualise person-anchored perspectives” (Hobson et al., 2006, p.153).

How Steven Gutstein views autism
What Gutstein came up with was an understanding of autism as consisting of areas of ‘core deficit’ that are present in every person on the autistic spectrum, (although there are individual differences within this) and which result in impaired social and emotional function, and the huge obstacle to quality of life, that is autism (Gutstein, 2000; 2004;2005 ).

Declarative (experience sharing) communication
Gutstein (2000), drawing on the work of Camaioni, (1997) distinguishes between two kinds of communication, declarative and imperative. Declarative is the kind of language we use to share experiences, our ideas, feelings, goals, intended actions, predictions, memories, plans etc. An imperative form of communication is what we use as a ‘means-to-end’; for example, acquiring information, testing or demonstrating knowledge, asking for someone’s service etc. Declarative language often has a rich non-verbal component and invites a type of response from the other which is never rote or scripted. Autistic people have an inability to share their experiences and feelings, so use little or no declarative language.

Referencing refers to the ability to ‘borrow’ another’s perspective, in order to help resolve uncertain situations, or to find reassurance. We might check out if the other is approving or disapproving, or if they are finding us boring or interesting. People who are autistic are often able to learn to recognize and label various facial expressions, but they are not able to ‘borrow’ or ‘read’ the other’s perspective during an interaction (Gutstein 2000).

Gutstein (2000) describes the back-and-forth ‘dance’ in interactions with others. This dance is always spontaneous, unpredictable, and reciprocal. Autistic people can learn to follow procedures and scripts, but not to ‘dance’ (Gutstein 2000).

Episodic (autobiographical) memory
Autistic people may have very good or even excellent procedural memory, but lack autobiographical, or episodic memory. This is very different to remembering details. It involves extracting from memories what is personally meaningful to the self, and using this to reflect on the past and anticipate the future. This allows us to avoid negative consequences, and repeat positive ones (Gutstein 2000).

Flexible thinking
Autistic people are able to understand rule-based, black-and-white thinking, but are not able to adapt their thinking quickly, accept what is ‘good enough’ or see grey areas. They struggle when it comes to being able to ‘go with the flow’ if plans change, and find it difficult to adapt to these changes (Gutstein 2000).

Hobson’s work
Hobson’s ideas follow on from a prevailing opinion that babies are born pre-programmed to acquire cognitive function and language. Hobson believes (along with a lot of psychotherapy theory) that this capacity develops through the baby’s interaction with other people over his/her early months and years of life. He views emotional engagement between the baby and caretaker as the vital part of mental development, and sees autism as a neurological condition that demonstrates the profound impact of what happens when this interaction is inhibited (Hobson, 2002).

Hobson arrives at his theories via several routes. The first of these is a clinical method of observation. For example, he cites the careful observations of Kanner’s early descriptions of autism, and the essence of detachment and inaccessibility of an autistic child.
To broaden the picture Hobson turns to experiment. By setting carefully designed tasks for groups of children with autism, and matched groups without autism, the picture becomes clearer.
In a third approach Hobson looks to psychoanalysis, which has a primary concern with “…the close connection that exists between what happens within an individual person’s mind and what happens between one person and another” (Hobson, 2002, p.22). Hobson credits this avenue as “casting light” on the kind of mental functioning that his observations and experimentation around autism have revealed (ibid). Hobson sees psychoanalytic research as responsible for alerting us to the developmental importance of the role of the caregiver in an infant’s ability to think.
Hobson sides with the view that the mother and infant are mutually engaged with each other in a genuinely reciprocal way; that is, they both modify their own reactions according to feedback from the other. For example, a baby may be delighting in the anticipation of a game of peek-a-boo, and smile towards a mother, in a way that suggests “we are sharing this” (Hobson, 2002, p.43). Hobson sees this kind of early communication as “providing a kind of scaffolding for the introduction of language itself”(p.43).

Hobson suggests that although autism is rarely diagnosed within the first year of life, there are possibly clues before this that something in a baby’s development is awry. Recorded interviews with parents have shown that those infants who were later diagnosed as having autism, showed less greeting and waving, less raising their arms to be picked up, and they were less liable to direct anger and distress towards people. They also failed to point at objects to share, or to bring an object to an adult to share.
Whereas typical babies are emotionally connected to people, and play their role in the communicative ‘dance’, for autistic children there is “something profoundly lacking in their orientation towards people…and… in their emotional engagement” (Hobson, 2002, p.59). It is against a backdrop of autism, Hobson believes, that we can understand the richness of what normal development entails.

He further suggests that we develop language “in order to affect the hearts and minds of others” (2002, p. 85). For autistic children, who do not “relate to the world-according-to-the-other” (p.88), there will likely be deficits. In fact, many children with autism never learn to talk, and Hobson observes that if the purpose of language is to communicate and share, for them acquiring language may appear pointless, except maybe in a simple form as a way of getting needs met. When they do acquire language in a more sophisticated form, autistic people have an oddness, in that they tend to understand only literal meanings, and fail to pick up on the subtleties of what the speaker really means.

In his research, Hobson compares autistic deficits to other barriers in communication. He explores what happens when mothers who are diagnosed with borderline personality disorder relate to their infants. Hobson found that these mothers were “less sensitive and more intrusive towards their infants than were the other mothers” He believes that the vital importance of interpersonal relationship, and its impact on the developing mind has been overlooked until recently (except among psychoanalysts).

Hobson also explores the case of congenitally blind children, and the curious frequency with which the clinical features of autism occur in these children (Hobson, 2002, Hobson, 2003, Biship, 2005). Hobson found that even for those children who were blind and did not show autistic features, their engagement with people was still severely affected. They had “the kinds of difficulty in social engagement that are typical of autism” (Hobson, 2002, p.192). Hobson concludes that this study provides further evidence on the serious nature of barriers in personal relations.

Similarly, in examining the findings of Michael Rutter (et al., 1999) of infants exposed to the terrible conditions in the orphanages of Ceausescu’s Romania, Hobson found that the appalling treatment of these babies, and the subsequent adoption of some of them into caring homes, revealed some unexpected findings, which dovetailed his own research with blind children, that this level of deprivation led to behaviours that were characteristic of autism (although these children also displayed behaviours a-typical of autism, such as making spontaneous efforts to communicate).
His hypothesis of autism as an intersubjective deficit, that happens between an affected person and others, accounts for the findings from these studies, as well as indicating the essential role of intersubjective experience in a developing self.

Hobson believes that “thinking cannot become a flexible and creative medium for human intelligence without passing through the minds of others” (2002, p.210-11). A vital part of experiencing oneself as a person is to feel a person among others. He writes: “In the course of our social interactions, each of us is pushed or pulled or nudged or drawn or wrenched towards the psychological position of the other”(ibid).
A part of this emotional responsiveness occurs in the action of “imitation”. Hobson believes it is the propensity that young children have to imitate their parents, that is “basic to our intellectual prowess” (Hobson, 2002, p.215). Hobson (et al’s) many experiments have demonstrated that although autistic children can easily imitate an action, they are not able, or moved, to imitate the quality or the style in which the person performed the action (eg. was it gentle or rough?) Matched groups of non-autistic children automatically did this.
This has implications for developing an understanding of a self. If a child is unable to identify with the characteristics of someone, and make them their own, they are unable to access a vital process that is happening all the time, and which involves continuous shifts into the roles and attitudes of others.
In spite of this, many autistic adolescents have “a very painful and moving awareness that they are not like other people” (Hobson, 2002, p.226). With the understanding that typical adolescents are “deeply preoccupied with how they compare to their peers” (ibid), Hobson and his colleagues administered an interview to two matched groups. Their results showed that although the group without autism, but with mild retardation, describe themselves as part of a richly social world, autistic adolescents did not describe themselves in the context of their relationships. Hobson believes that without a propensity to take on the attitudes of others, a process involving identification, we cannot “acquire the special human form of self-reflective awareness” (p.238). Hobson concludes that

An implication is that facilitating the development of communicative skills among
individuals with autism may involve more than teaching specific forms of behaviour, and
instead require a focus on affective relatedness in order to foster more person-centred
engagement (Hobson, Lee, & Hobson, 2007, p.329).

In his first book, Gutstein (2000) describes his dissatisfaction with the results he was achieving in his work with autism. Although his patients made good eye contact, were tolerated by their peers, and received excellent grades for conduct, it felt as if something very important was missing.

Even for these highest functioning children, their abilities were not enough to have a real caring friendship with another child…None could, on their own, maintain the topic of his conversation with a pal, or share a tender moment. Some key element was missing that kept them from learning the critical parts of friendship
(Gutstein, 2000, p.xvii).

Gutstein began studying and consulting with world experts in the fields of child development and neurology. One of his fundamental discoveries was the difference between what is called instrumental interactions, and those which are referred to as experience sharing. His research showed that Autistic Spectrum Disorder (ASD) people could function well for instrumental purposes, (where interaction serves as a means to obtain a desired object or outcome), even displaying behaviors usually considered missing in people with ASD, such as eye contact and showing affection (Gutstein, 2000).

Experience sharing involves sharing a part of oneself with a partner. It is the reason we desire and enjoy the company of others. Gutstein concluded that what he had been working on with his patients was an instrumental style of development, and what was being left out was experience sharing. Referring to Hobson’s work, Gutstein began to understand autism as a range of neurological disorders that children are born with, which “…collectively interfere with the type of information processing that makes Experience Sharing so simple for the rest of us” (Gutstein, 2000, p.xix). Autistic people are not able to link their own feelings and experiences to the continuing stream of emotional information that surrounds them. This limits their capacity to perceive others’ emotions, or to enjoy and participate with others in a meaningful way.

Realizing that social skills were still being taught in an instrumental way, Gutstein returned to the literature, believing that an effective clinical treatment would parallel typical children in the way they develop this capacity. Working alongside his wife, Dr. Rachelle Sheely, (also a Ph.D. in Clinical Psychology, with a primary interest in autism), Gutstein created RDI.

Relationship Development Intervention (RDI)
Rather than providing instruction in skills, RDI is designed to engage the child with a parent in on-going interactive ways, which are fashioned to follow a progressive developmental path. Psychotherapy theory might refer to this as empathic attunement (Kohut, 1977). Prior to beginning this work, there is a careful assessment, over several days, to ascertain where the child might be on that pathway, their particular strengths and limitations, and the parents’ strengths and obstacles.

An emotional feedback system
Competence in experience sharing is something which happens in a gradual systematic fashion in typical development, with mastery of early abilities being the springboard for new challenges (Hobson, 2002; Rogoff, 1990; Sroufe, 1995). For typical children, there is parent-infant emotional feedback, which helps parents regulate this sequence (Fogel, 1993; Sroufe, 1995; Tronick, 1989). However, with ASD children, there is an absence of this emotional feedback, so that parents are unable to gauge their infant’s emotional state, and the infant is unable to use or interpret their parent’s emotional expressions.

RDI teaches parents to use simple activities to promote this feedback system. For example a parent might use a gentle rocking game such as ‘row-your-boat’. A client, Anna, had become adept at building shared anticipation, with her child, Sam. In games of ‘ring-o-roses’ on the trampoline, she delayed the “all-fall-down” until Sam, glanced at her exaggerated, wide-eyed smiling face. Eventually, after many games like this, he had an almost matching expression on his own face, until they fell down together. In their daily life, Anna included Sam in simple activity, such as helping her carry the laundry basket to the laundry and put the clothes into the machine. She was able to build anticipation around holding up clothes and dropping them in. As Sam’s understanding about the world developed, she pretended to drop in something silly, eg a cup or a saucepan, and they laughed together about how silly that was. All of this was about their becoming an ‘us’, not about getting the laundry done efficiently!

Apprenticeship in co-regulation
Parents of typically developing children act as, what Gutstein (2005) calls “senior co-participants in interactions with their children” (p.9). They carefully regulate the degree of support their child needs to participate with them in an activity, so that both experience enjoyment and success. They allow them just enough of a role. ASD children fail to master this co-regulation system. RDI teaches parents to “…carefully pace their demands for co-regulation…” (Gutstein, 2005,p.10). They need to ensure that their child is maintaining their on-going social referencing, while supporting their children in developing a sense of self efficacy, and to share in social interactions. Success in this motivates children to want to be co-participants in these encounters.

Sam’s Dad would spend time playing simple ball games with Sam. At first Sam would get the ball and run off with it, but a few months later, he was very much part of the game, he knew his role, his siblings were included, he could follow the rules, and there was look of delight and competency on his face. There was no longer any suggestion of him running off with the ball.

Participating in dynamic systems
Social relationships involve constant changes and challenges, with new information creating a disruption to a child’s existing cognitive state. Typically developing infants thrive on this variety and benefit from it, using it to develop more sophisticated ways of understanding and organizing their experiences. For example, they adore playing games such as ‘peek-a-boo’. ASD children do not want to play these games and lack the ability to take part in activities where there is change and novelty. Rather, they seek static, predictable activity where they know what will happen. (Video and computers are examples of static and predictable activity, and many ASD children are obsessive about these).

A particularly delightful game Anna invented involved Sam sitting on a ledge that divided their lounge and dining room. Anna sang a chant, while holding both his hands,

“Here’s my little Sam
sitting on the ledge
I think he wants a ….”

At this point Anna would say, after a pause to build anticipation, “kiss” or a “hug” or a “tickle” or a “raspberry” (etc) and would act out the action. The game ended with a “fall down” where she gently pushed Sam so that he fell onto the sofa amidst great hilarity. During this game, there were many shared excited glances. It contained enough predictability to keep Sam feeling competent, and therefore engaged, while introducing unpredictable changes. I was delighted to watch how engrossed Sam was in the game, as tolerating these differences is a real sign of progress. It was at this stage, I believe, that Sam began to understand that it was more rewarding to be involved in a game with his Mum, than a game by himself.

RDI parents learn to add these unpredictable moments in small, manageable amounts, usually into known games, then gradually to build this up, allowing the child the opportunity to take this up and become an active participant.

Developing declarative communication
ASD children tend to almost exclusively use an ‘imperative’ form of communication, which is instrumental, that is, directed towards having one’s needs met. Typical language consists of a larger proportion of ‘declarative’ language, (around 80%) which is language that shows an intent to share with others something of one’s experience (Camaioni, 1997; Tomasello & Farrah, 1986).

RDI parents learn to emphasize a declarative language style, and to slow down and simplify their language to enable their child to process what they have said and think about their reply. Parents are taught not to over-talk, or use prompting techniques such as questioning to elicit responses from their children. eg. Instead of “Pick up your bag”, they might say, “Uh-oh, your bag is on the floor!”. And instead of “Go and clean your teeth” they might say, “Yuk, your teeth are really dirty”.

Constructing optimal learning environments
Without the advantage of having mastered the foundations of experience-sharing in their infancy and toddler years, children with autism are hugely vulnerable to objects and activities in their environment that distract them and compete with social partners for their attention

RDI parents learn to simplify their environment, as well as the general pace of everyday life. There needs to be time throughout the day to practise their newly emerging experience-sharing skills. Gradually, parents are able to increase the amount of environmental ‘noise’ to a level that is more like the real world.

RDI Theory and Psychotherapy
Because RDI is built on a relational model, my argument is that it has many parallels within psychoanalytic theory, and that many of the concepts that are proving to be useful in an effective clinical treatment are fundamental concepts in psychotherapy.

I see an essence as being similar to an object relations view. In object relations theory, the self is seen to exist only in relation to other selves (objects), which may be internal or external. Internal objects are formed from early interactions with parents, for which infants are ‘hardwired’, and the patterns of these interactions are what form the “prototypes for all later experience of connection with others” (Mitchell & Black, 1995, p.116).

The famous Winnicott statement, that “There is no such thing as an infant, …wherever one finds an infant one finds maternal care, and without maternal care there would be no infant” (Winnicott, 1958, p.xxxvii), feels at the heart of this work. Because an autistic child is unable to make use of maternal care (Hobson, 2002), it is almost as if there is no infant.

William James described an infant’s reaction to the world as a “booming buzzing confusion” (cited in Modell, 2005, p.556). From an object relations view, a human infant is predisposed to respond to this environment and to find meaning that shapes their world, in the affective responsiveness of its caregivers. I argue, that because the autistic child is unable to make use of the care-giver to navigate their world, (Hobson, 2002), that they remain in a state of anxious confusion.

In RDI, it is recognized that before we can begin work on the developmental objectives, it is necessary to establish an activity, or activities that will function as a soothing phenomena for these children. For example, with Sam, we invented a gentle rocking game, that we called ‘Tick-Tock’ where he lay on the floor and Anna held his legs and rocked them side to side. The game had a simple repetitive chant, and this became a reliable way to sooth. In RDI this is referred to as “regulation”, but I also think of it in terms of what Winnicott called, “transitional phenomena”. Winnicott said that transitional phenomena, “…shall exist as a resting-place for the individual engaged in the perpetual human task of keeping inner and outer reality separate yet inter-related” (Winnicott, 1953, p.90). He observed that sometimes a tune could act as a transitional phenomenon, (cited in Roiphe, 1973) and it was as if the familiar, rhythmic, dependable chant and actions, became associated with comfort from his mother, and so therefore “…a defence against anxiety” (Winnicott, 1953, p.90).
For Winnicott’s client, and for my client, it was as if this resting place allowed him the space to engage in the task of beginning to relate to his Mother and his world. Winnicott referred to this as the “potential space between the individual and the environment” the use of which is determined by early life experiences, and that having this space is dependent on “experience which leads to trust” (Winnicott, 1967, p.370-72).

Hobson described how the infant is disadvantaged when caregivers are less able or willing to engage with an infant. With an autistic child, it is the other way around, in that it is the child who is less able to engage with the parent. However, the end result is the same, in that there is an absence of “experience leading to trust”. In our work with this client, being able to establish this simple, calming rhyme, was the beginning of trust. From this point we could move on towards “playing”.Winnicott said of play, that it is:

universal, that it belongs to health: playing facilitates growth and therefore health; playing leads into group relationships; playing can be a form of communication in psychotherapy; and, lastly, psychoanalysis has been developed as a highly specialized form of playing in the service of communication with oneself and others” (Winnicott, 1971, p.41).

In working/playing with autistic children, there is not a natural flow of play, we need to pay attention to detail in a concrete way, in order to facilitate the kind of responses that are easy and natural for non-autistic children. Progress in the beginning is slow and involves a huge investment of emotional energy and commitment. As children become more connected and begin to enjoy being actively involved with a parent, there is a feeling of connection and “play”. From this point, as Winnicott says, “there is growth, and therefore there is health” (ibid).

Winnicott saw the ability to “use the object” as being related to this capacity to play. However, he believes that this is not inborn, but is dependent on a facilitating environment. “To use an object the subject must have developed the capacity to use objects” (Winnicott, 1969, p.713). He describes a maturational sequence, where first there is object-relating. In object relating the object has become meaningful, but “the experience of the subject is of an isolate” (p.712). Next, there is “the most difficult thing…the subject’s placing of the object outside the area of the subject’s omnipotent control…in fact recognition of it as an entity in its own right” (p.713).

This sequence defined by Winnicott feels to have a parallel in RDI. In the beginning we strive for brief moments of connection, which we recognize in the shared excited glances that gradually begin to occur as anticipation builds in games like ‘peek-a-boo’, or in shared “One-two-Three…, GO” games. When this begins to happen regularly, it feels as if we have achieved ‘object relating’, and that the parent is now meaningful to the child. With this established, we then move towards Winnicott’s “most difficult thing…” and RDI’s dozens of carefully crafted tiny steps that make up a “facilitating environment”, and which need to happen before there can be “object use”.

Winnicott wrote that, for certain patient groups (borderline), there needs to be a concern with the development of a capacity to use objects He describes the ‘joy’ of allowing a patient to arrive at creative understanding, by waiting rather than attempting ‘clever’ interpreting (Winnicott, 1969). He believes that for interpreting to have an effect, the patient must have the ability to use the analyst, and that in our work we need “to be concerned with the development and the establishment of the capacity to use objects and to recognize a patient’s inability to use objects when this is so” (p.711).

Modell describes the means by which a patient is “raised to a higher level of relatedness” as depending on both the patient’s strengthening of self, and the ““borrowing” of the analyst’s consciousness” (Modell, 1990, p.122). Modell refers to Sterba’s contribution to this concept of “borrowing”, stating that the “analyst serves the learner as a vicarious form of consciousness until such time as the patient is able to master his own consciousness” (p.124). Similarly, Anne Alvarez, a child psychotherapist at the Tavistock, has suggested, that for very depersonalised patients, the therapist may have to carry the feeling, and that it does not matter who has the feeling first, that the patient may be testing whether or not it is safe to have feeling states at all (Alvarez, 1993, p.117). These concepts feel like a match to RDI, where we encourage parents in the beginning to have their own emotional responses alongside their autistic child, rather than attempting to illicit a response from the child.
I argue that for some patient groups, a facilitating environment would have some resemblance to RDI, in that there is a need for something new to grow. In RDI this capacity is being built from the beginning, and although the techniques used cannot directly apply to psychotherapy clients, there is still an important reminder of a maturational sequence; that is, that object use cannot occur before there is a foundation of object relating, and a “gradual build up of the individual’s capacity to play” (Winnicott, 1969, p.711). In her work, Alvarez has suggested that sometimes, rather than thinking about “helping patients reintroject parts of themselves “…something may need to grow for the first time” (Alvarez, 1993, p.120-21). In its relational approach, and intricate developmental steps, first towards what could be described as object relating, then towards object use, I argue that RDI is adding support to Winnicott’s theory, and to Alvarez’s observations.

An intersubjective view
While object relations theorists have observed the primacy of personal relatedness, intersubjective theorists talk about a dynamic systems theory, which works towards illuminating interweaving worlds of experience. “For us an intersubjective field – any system constituted by interacting experiential worlds- is neither a mode of experiencing nor a sharing of experience. It is the contextual precondition for having any experience at all” (Orange et al 1997, cited in Stolorow, Orange, & Atwood, 2001, p.371). Stolorow describes an “embeddedness” of an individual’s world “with other such worlds in a continual flow of reciprocal mutual influence” (Stolorow, 1997, p.338). This is a fit with Gutstein’s understanding of the back-and-forth dynamic ‘dance’ of relationship as always spontaneous, unpredictable, and reciprocal. .Autistic people, although they can learn to follow procedures and scripts, are not able to ‘dance’.

Stolorow views the child-caregiver system as fundamental in the organization of a child’s experience (Stolorow, 1997, p.339-340). Jessica Benjamin describes how “very early on we find that recognition between persons – understanding and being understood, being in attunement – begins to be an end in itself. …By our very enjoyment of the other’s confirming response, we recognize her or him in return” (Benjamin, 1990, p.37). She describes the development of a “capacity for mutual recognition” (p.37). As a child begins to recognize a mother’s subjective experience, she/he moves from a “retaliatory world of control to a world of mutual understanding and shared feeling” (Benjamin, 1990, p.40). Similarly, Fonagy describes how it is “the consequence of being active observers of the functioning of other minds as well as being the subject of their observation” that we become aware of our own subjective state (Fonagy, Steele, Moran, Steele, & Higgit, 1993, p.982).

These descriptions of Stolorow, Benjamin and Fonagy reflect what Gutstein and Hobson describe as missing in autistic people. Referring to Hobson’s work, Gutstein explains how the capacity of autistic people to enjoy others is limited by their incapacity to link their own feelings and experiences to a continuing stream of emotional information.

RDI, psychoanalysis, and understanding autism
Throughout this paper. my central argument has been that RDI could be interpreted as a psychoanalytic approach, and that it is psychoanalysis that has provided the necessary theory and research to support a programme that aims to make the kind of cognitive changes needed to allow autistic people a quality of life.

In RDI there is a similar profound respect for the child-caregiver system that is an integral part of much psychodynamic understanding. RDI implements this belief in working to empower parents to be the therapists for their child. In comparison, for a psychotherapist, even with their knowledge of a relational and empathic system, the tiny amount of time they could spend with a child would be insignificant in light of their enormous deficit and need. In RDI there is a complete ‘re-do’ of the early years, and Gutstein has suggested that there are thousands of hours of time to be made up (Gutstein, 2000). RDI equips parents with the knowledge and skills to parent their child. It has been my privilege in working with these families to witness the “joy” that is part of their reconnecting in a relational way to their children, which reminds me of the joy that Winnicott talked about. I see a parent’s absolute delight when their autistic child begins to ‘nag’ in the ‘annoying’ way that non-autistic children do, for their parent’s attention, with that robust, insistent, “Mum! Mum!…MUM!!” Their joy at seeing their child become curious about other children and want to play, to see the beginning of empathy when another child is upset, and their child makes appropriate attempts to help, and to see their child want to share their own triumphs. An RDI parent becomes acutely aware of the experience and feeling of connection, and of these mile stones which go un-noticed in the development of a non-autistic child. It is deeply moving to watch video of these families working with their child, and witness child and parent revelling in each other’s company.

In contrast to earlier mother blaming psychoanalysts, Hobson’s (2002) work has been guided by an understanding of autism as a neurological disorder. Although he has not been involved in the development of a clinical programme, his detailed and extensive research, and multi-disciplined approach have yielded crucial insights into the disorder, which Gutstein has been able to take up in the development of RDI. These studies are on-going, with recent research suggesting the vital importance of imitation and identification in typical development. Interestingly, Freud said that “ a path leads from identification by way of imitation to empathy, that is, to the comprehension of the mechanism by means of which we are enabled to take up any attitude at all towards another mental life” (Freud,1921, p.110, fn 2).

In both psychotherapy and RDI, there is a fundamental recognition of the nature of how real communication “involves affecting and being affected by someone else” (Hobson, 2002, p.259). In Fairburn’s words, “what man seeks most deeply is emotional contact with his fellow human beings” (cited in Symington, 1986, p.238). Gutstein’s belief in this capacity for emotional intimacy, no matter what the obstacle, has been the compelling force behind his life’s work in confronting the deficits of autism.

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My name is Colleen Emmens I have been a primary school teacher for most of my life, where I developed a specialty area in early literacy and in working with young teachers. Later, after a gap of ten years at home having become a mother of four children, one of whom had ASD, I became passionate in working with what could be described as children at risk of ‘falling through the cracks’ of the school system. As my children became teens and adults, I began further part time study in related fields, and following a teaching stint in Asia for two years, decided to return to university where I completed a Masters in Health Science, majoring in psychotherapy. During this time, one of my grandchildren was born severely autistic, and through this, began my interest in autism, and my study to become a consultant in a programme called Relationship Development Intervention, or RDI. I am constantly struck by the parallels between working with RDI and with psychotherapy, and the power that relationship has to heal. I also believe that autism demonstrates what psychotherapists know, that is how vital the role of relationship is in normal development. I now work both as a psychotherapist, and with families affected by autism.

Freud on homosexuality – Andrew Kirby

November 12, 2008

For clients who struggle to accept their same-sex attraction and experience their homosexuality as ego-dissonant(1), the literature is clearly split between two major therapeutic traditions, both offering a ‘cure.’ Conversion therapy and gay-affirmative therapy, which the author has reviewed elsewhere (Kirby, 2008), each tend to respond with a limited, exclusionary choice to be either an ‘out’ gay or an ‘ex’ gay; to accept or reject one’s sexual orientation. On the one hand, there are those who argue that some variety of treatment – whether formal conversion therapy conducted by a professional practitioner or a self-help ‘ex-gay’ group – should be available for those who experience their same-sex attractions as incompatible with competing values or beliefs (Throckmorton, 2002; Yarhouse & Burkett, 2002).

On the other hand, proponents of gay-affirmative therapy consider antigay social stigma and internalised homophobia, not sexual orientation, as the primary motivator of those seeking to change their sexual orientation. These authors (e.g., Liddle, 1996; Schidlo & Schroeder, 2002) question the justification and ethicality of sexual reorientation when homosexuality is no longer considered a mental illness and highlight the potential harms to those who attempt conversion therapy.

The ongoing debate between conversion and gay-affirmative theorists about the appropriateness and efficacy of these psychotherapies has, however, rendered dichotomous explanations insufficient for some clients for whom neither model is appropriate. These individuals are unable to resolve perceived irreconcilable differences between sexual feelings and opposing values/beliefs which can stem from holding traditional values regarding marriage and family, or religious beliefs that view homosexuality as unnatural and immoral. More recently, emerging integrative solutions have begun to appear in the literature offering an alternative treatment option to such individuals who value competing aspects of their identity equally (Gonsiorek, 2004; Haldeman, 2004; Yarhouse, 2006).

However, as a first step I had a look at what Freud had to say on the topic, and this article examines his views on homosexuality in relation to his psychosexual developmental theory, whether he believed same-sex attraction was constitutional or acquired, and his thoughts on sexual reorientation.

Constitutional bisexuality
As founder of the psychoanalytic school of psychology, Freud made numerous references to homosexuality (1905, 1908, 1909, 1910, 1911, 1914, 1920, 1922). Taken out of context, Freud can be portrayed as either virulently anti-homosexual (Nicolosi, 1991) or as a closeted friend of gays (McWilliams, 1996); this contradiction has been used to promote both sides of a polarised debate on the theory and treatment of homosexuality.

Freud’s view on homosexuality was certainly tolerant for its time. In 1930, Freud signed statements calling for decriminalisation of homosexual acts in Germany and Austria (Abelove, 1986). When asked whether one ought to undertake to cure homosexuals or make their lot easier by increasing society’s tolerance, he replied, “Naturally, the emphasis ought to be put on social measures” (Wortis, 1954, p. 56). Freud understood the burden to be lifted from homoeroticism primarily as a burden society had itself placed there.

Freud disputed degeneracy theories’ pejorative views (e.g., Krafft-Ebing, as cited in Drescher, 2001), asserting that humans were by nature bisexual. He believed homosexuality to be a variation of the sexual function produced by arrest of sexual development, and attributed homoeroticism to insufficient repression of the original bisexual disposition. Freud argued that a sublimated homosexuality was necessary for normal heterosexual function. Similarly, all homosexuals had some heterosexual feelings.
Yet, despite his view of constitutional bisexuality as the origins of homoeroticism, and efforts to protect homosexuals from social malevolence, Freud never asserted complete parity between homoeroticism and hetero-eroticism (Weeks, 1985). Freud understood homoeroticism as undesirable (if blameless) sexuality when it was the primary erotic orientation in an adult (Drescher, 2001; Murphy, 1992) and believed heterosexuality and reproduction to be the goal of sexual maturation (Freud, 1905, 1925).

Freud recognised homosexuality in people whose efficiency is unimpaired, and who are, indeed, distinguished by specially high intellectual development and ethical culture such as Plato, Michelangelo, and Leonardo da Vinci (Freud, 1905, 1935). He believed homoeroticism was not eo ipso a pathological condition, stating, “I am of the firm conviction that homosexuals must not be treated as sick people… wouldn’t that oblige us to characterize as sick many great thinkers and scholars whom we admire precisely because of their mental health?” (quoted in Lewes, 1988, p. 32). His resistance of pathological interpretation of homoeroticism is evident in the Dutch psychoanalytic association’s inquiry about whether a homosexual man should be admitted to psychoanalytic training. Freud declared, “We cannot exclude such persons without other sufficient reasons, as we cannot agree with their legal persecution… a decision should depend upon other qualities of the candidate” (quoted in Abelove, 1986, p. 60).

Psychosexual developmental model
Freud theorised that early childhood development was organised into psychosexual stages of libido, moving from oral to anal to genital stages. Adult sexuality was defined as penile-vaginal intercourse, and oral and anal sexuality were labelled immature vestiges of childhood sexual expression. Homosexuality could be due to a libidinal arrest (in the phallic stage) or failure to reach the final psychosexual stage of genitality due to a blockage of the energic force. Alternatively, an individual had reached the more mature genital stage but due to trauma reverted to an earlier stage. This was termed libidinal regression. For Freud, changing an individual’s same-sex orientation to a heterosexual one meant helping them ‘grow up’ through achieving a higher level of psychosexual development, rather than a ‘cure’ (Drescher, 2001).

Aetiological theories of homosexuality
During his lifetime, Freud posed four different theories of the aetiology of homosexuality (Lewes, 1988). In each, he addresses a different metapsychological issue in relation to homosexuality, i.e. libido and bisexuality (1905), narcissism (1910, 1914), projective mechanisms (1911, 1922), or unsatisfactory Oedipal resolutions (1920, 1922). Each theory refers to a narrowly constructed ‘hypothetical homosexual’, which Freud used to hypothesise different psychodevelopmental events possibly involved in the emergence of adult homosexuality (Drescher, 2001):

1. Homosexuality arises as a result of the Oedipus conflict and the boy’s discovery that his mother is ‘castrated’. This produces intense castration anxiety causing the boy to turn from his castrated mother to a ‘woman with a penis’.
2. In the Three Essays, Freud (1905) theorised that the future homosexual child is so over-attracted to his mother that he identifies with her and narcissistically seeks love objects like himself so he can love them like his mother loved him.
3. If a ‘negative’ or ‘inverted’ Oedipus complex occurs, a boy seeks his father’s love and masculine identification by taking on a feminine identification and reverting to anal eroticism.
4. Finally, homosexuality could result from reaction formation(2): sadistic jealousy of brothers and father is safely converted into love of other men.

While Freud believed the expression of homoeroticism has psychological origins, he did not believe psychoanalysis alone could solve the problem of homosexuality. He argued that explanation beyond this belonged to biology (Freud, 1920). As a result, Freud cautioned against seeing homosexuality as either unequivocally acquired or congenital (Murphy, 1992).

Sexual reorientation
In Three Essays on the Theory of Sexuality, Freud (1905) separated sexual behaviour from gender, thus founding a radical and invaluable way of thinking about diversity of sexual experience and expression. However, Freud recognised that Oedipal theory, central to his project concepts, depended on maintaining what Sinfield (as cited in Davies & Neal, 1996) called ‘the cross-sex grid’(3). The cross-sex grid had its origins in 19th century Victorian dominance and oppression of the heterosexual family mode over all possible other modes. Although Freud acknowledged his own inability to completely enter this new discourse, it is this early concept of the separation of human sexuality from gender that forms the basis of many gay-affirmative psychoanalytic writers (Davies & Neal, 1996; Isay, 1986; Izzard, 2000; Roughton, 2002; Rubinstein, 2003)

In his Letter to an American Mother, Freud (1935) reassured a woman that her homosexual son was not ill: “Homosexuality is assuredly no advantage, but it is nothing to be ashamed of, no vice, no degradation. It cannot be classified as an illness” (quoted by Anderson, 2001, p. 23). Drescher (2001) believes Freud used the term illness as a synonym for symptom formation, by which he meant the product of intra-psychic conflict. Freud went on to suggest analysis might help in a different way, “If he is unhappy, neurotic, torn by conflicts, inhibited in his social life, analysis may bring him harmony, peace of mind, full efficiency, whether he remains a homosexual or gets changed” (quoted by Grotjahn, 1951, p. 331). In this case, Freud does not view homosexuality as an illness – rather an un-conflicted expression of an infantile sexual wish. Neither does he believe it implies health (Freud, 1905, 1920). In suggesting the benefits of psychoanalysis, regardless of whether change occurs, Freud does not reject the idea of sexual reorientation outright, although neither does he seem optimistic. It appears that Freud was not so much invested in the outcome of the therapy with regard to sexual orientation as attending to an individual’s inner conflict in order to bring about peace of mind.

There is nothing in Freud’s notion of bisexuality that rules out the possibility of sexual reorientation. Some authors (Bieber et al., 1962; Nicolosi, 1991; Ovesey, 1969; Socarides, 1978) have assimilated Freud’s understanding that sexual gratification found in people of one anatomy at one point in life does not rule out later change in the intensity of direction of sexual desire. This hypothesis has come to form the basis of contemporary conversion therapies.

Opponents of conversion therapy (Drescher, 2001; Isay, 1989; Murphy, 1992) highlight Freud’s (1905) views on bisexuality in Three Essays on Sexuality, where he rejects the idea that individuals could be born with object choices already determined prior to psychosexual development. This seems to be aimed at those claiming homoeroticism to be an innate condition. Freud also rejects the ‘third sex’ view(4). Yet, in stipulating constitutional bisexuality in people, it seems hard to understand Freud saying something other than homoeroticism will come to the fore in certain persons independent of their psychic environment.

According to Wortis (1954), Freud claimed some people had a special susceptibility to homoeroticism. In Psychogenesis of a Case of Homosexuality in a Woman, Freud (1920) believed constitutional factors determined the intensity of the homoeroticism in an eighteen-year-old girl. While accepting this patient for the purposes of sexual reorientation, Freud noted that such a case was not attractive to psychoanalysis because it did not begin with the personal suffering of a divided personality. To the contrary, his patient did not suffer at all from her attraction to other women. Freud (1920) cautioned that removal of homosexuality was never easy and success found only in especially favourable circumstances, “and even then the success essentially consisted in making access to the opposite sex… thus restoring him to full bisexual functions” (p. 151). He concluded that, “to convert a fully developed homosexual into a heterosexual does not offer much more prospect of success than the reverse, except for the good practical reasons the latter is never attempted” (p. 151).

Freud did not think homosexuality was pathological in the sense that it was the consequence of degenerative physiology or psychology. He found homoeroticism compatible with normal psychological functioning and even associated it with elevated capacities and superior psychic and moral qualities. However, Freud did believe homosexuality represented stunted individual psychosexual development and from this perspective saw it as inferior sexuality in a mature adult. There is nothing in Freud’s writings to suggest that conversion therapy is desirable or successful. In fact, he suggests caution to those who pursue such a direction with an individual who is suffering from his or her sexual orientation. In most discussions regarding ego-dissonant homosexuality, Freud left the prospect open.


1. Ego-dissonant describes individuals who struggle to integrate their same-sex attraction with competing aspects of their identity. Dissonance stems from the words ‘dis’ meaning ‘lack of’ or ‘apart’, and the Latin ‘sonans’ meaning ‘sound’ or ‘accord’. Together they describe a ‘discord’ or ‘lack of agreement or consistency’ with the ego or conscious ‘I’ (Harper, 2001).

2. Reaction formation is a psychological defence mechanism in which one form of behaviour substitutes for or conceals a diametrically opposed repressed impulse in order to protect against it (McWilliams, 1994).

3. In Oedipal theory, the ‘cross-sex grid’ refers to bipolar explanations of genders and sexualities as ‘opposite’ to one another.

4. The ‘third sex’ view was that male homoeroticism resulted from a female mind in a male body. Female homoeroticism was the opposite.


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McWilliams, N. (1996). Therapy across the sexual orientation boundary: Reflections of a heterosexual female analyst working with lesbian, gay and bisexual clients. Gender and Psychoanalysis, 1, 203-221.

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Andrew Kirby was born in Zambia and raised in Zimbabwe where he remained until he immigrated to New Zealand in 2003. On leaving school he spent five years in the allied medical profession, initially as an Orthostist and Prosthestist (measuring, manufacturing and fitting of artificial limbs and orthopaedic appliances) and later working in the pharmaceutical industry. At 23 Andrew formed a business partnership – establishing a recruitment and human resources consultancy – and spent the next 20 years developing his business into a regional operation throughout central and southern Africa. Whilst his business interests were primarily focused in recruitment and human resources, Andrew was also involved in establishing a successful advertising agency and owned a popular restaurant in Harare for several years.

Since moving to Auckland, Andrew undertook a master of health science degree in adult psychotherapy and now works as a psychotherapist. His clinical experience has been gained with the New Zealand AIDS Foundation and Auckland Sexual Health Service, and he runs a part-time private practice in Ponsonby

Monetary issues in psychotherapy – Ivor Tomasevich

November 12, 2008

This paper discusses money-related-issues that may arise when working with fee-paying patients in psychotherapy.

I address the following:

• the idea that the monetary issues in therapy are sometimes used as means of communication from the patient as much as words are
• the approach of addressing monetary issues as a clinical material
• the nature of monetary issues
• various ways of addressing monetary issues
• monetary issues in relation to the duration of the therapy process
• monetary issues in relation to the patient’s level of mental health
• monetary issues and the method of fee-payment
• monetary issues in relation to the concept of counter-transference
• monetary issues in relation to psychotherapy as the “helping profession”
• discussion of case material

The paper does not address any specific issues the therapists themselves may have around money. However, the basic principles discussed are thought to be universal, i.e. applicable to any person and any situation. For the clarity of argument the topic is discussed from a standpoint where the patient contributes the therapeutic material and the therapist remains a neutral analyst of that material.

All patients’ names used in this paper are fictional.


Communication as Energy and the Psychotherapy Frame

The Psychotherapy frame

The psychotherapy “frame” is a set of conditions typically associated with the practice of therapy and agreed upon by the patient. E.g. patients are provided consultation under the following conditions:

• at the location of the therapist’s consultation room;
• at a previously-agreed time schedule;
• for a duration of 50 minutes;
• for which they pay a certain amount of money;
• payable at the time of the appointment;
• etc.

Any variation exerted by the patient and not previously discussed with the therapist can be considered to be an influence on the frame. For example, the patient turns up at the therapist’s office at a time different to the agreed time, unannounced, and wants the therapist to take him in. As such, this action can be interpreted as a form of “communication” from the patient, but a form different to that used during the therapy session.

One of the major areas of the psychotherapy frame that can get influenced by the patients’ communication outside the therapy session is the area of the frame related to money.

Money-related-issues include:

• fee-amount (the $ amount the patient pays for the therapy session)
• time of payment (before the session, immediately after, beginning of the month, etc.)
• payment method (cash, cheque, internet bank payment, etc.)
• fee-subsidy (weather the patient pays the “market price”, only a part of it, or none at all)
• therapist’s cancellations policy and holidays policy (the details around the payment for these situations)
• specific requests from patients to deviate from the usual arrangement the therapist works by (in any of the above) or a rigid insistence from the patient on carrying forward a former arrangement despite the change in relevant circumstances

Other areas of the frame that can get influenced are for example issues around the time (time of the appointment, the duration, frequency of sessions, etc), policy around the phone-calls, etc. The issues related to these other areas of the frame are not discussed in this paper.

Communication as Energy

Science of physics suggests that all creation we perceive is essentially energy. All energy is fundamentally just one and the same. However, energy can be manifested in various ways. Some forms of energy are directly visible while others can only be seen indirectly through the manifestations they produce. Energy can be transmuted from one form to the other but its sum total stays the same – i.e. no portion of energy can disappear altogether.

If this definition is adopted and translated to the psychotherapy situation, it can be said that any communication in therapy is also an exchange of energy. The use of the verbal/paraverbal/nonverbal communication can be interpreted as a directly perceivable form of energy while the meaning of that communication can be gathered only indirectly through the manifestations (thoughts, feelings, sensations, etc.) that that communication evokes in the therapist (i.e. the counter-transference).

Communication in psychotherapy is largely about the verbal/paraverbal/nonverbal communication during the therapy hour but not entirely so. As the “sum total” of the communication is always the same it follows that whatever pressing psychic energy the patient presents can’t be communicated during the therapy hour in view of it being transmuted into a healthier way of being is going to have to be communicated elsewhere and through other means.

When thinking about psychotherapy, this “elsewhere” is the psychotherapy frame and these “other means” include any money-related issues.

While a portion of any monetary exchange can be directly perceived (and can also be called “objective”), there is also a portion of that communication that can be only indirectly perceived if the therapist investigates the meaning of that particular monetary situation. E.g. a patient usually pays for his sessions by cash but on occasion he uses cheques. While the objective difference is directly perceivable, the possible meaning for this patient doing so can be gathered only indirectly. One of the tools available for investigation of the monetary issues is the counter-transference.

Mindfulness of the Psychotherapy Frame

In psychotherapy, patients bring their psychic energy in a particular psychodynamic form being played out in the patient-therapist field. It is in that field that the patient can more fully re-experience and re-evaluate the past events of their life as well as of their current situation. Any life situation or event can subjectively (emotionally) be experienced either as positive or negative for us, or we can have an emotionally non-charged (neutral) stance towards it. Patients seeking psychotherapy often have inner conflicts in that they perceive one and the same situation as both positive and negative. Through the process of therapy, such previously conflicting situations can eventually be perceived as neither negative nor positive for the patient but rather in an emotionally non-charged (i.e. neutral) way. In terms of energy, we can say that one form of energy has been transmuted into other, which we call healthier.

In an ideal psychotherapy situation the conflicting experiences would be brought forward by the patient within the therapy hour only and through using only words. However, as these conflicts are integral to the patients’ way of being and are a part of their everyday behaviour those conflicts are likely to have influence on the therapy process outside of the therapy session, i.e. on the therapy frame.

The more the psychic conflicts are being exhibited outside the consultation room (i.e. outside of the immediate reach of the appropriate clinical examination and interpretation by the therapist) the lower the chances for the patient to resolve their conflicting experiences. Conversely, a thorough attention to the psychotherapy frame ensures maximum benefits to the patient from the therapy. Monetary issues being a major area of the psychotherapy frame it follows that all such issues need be carefully and thoroughly explored.

Mindfulness of the existence and the importance of addressing any money-related-issues at the psychotherapy frame sets a necessary frame-work for a successful therapeutic outcome.

Instrumental and non-instrumental monetary issues

All monetary issues arising during the course of therapy can be categorized as either:

1. Instrumental
– being essentially an unconscious attempt on the patient’s part to achieve a sense of control over the therapy process through the manipulation of the monetary arrangements currently in place, or

2. Non-instrumental
– being a product only of the changed relevant circumstances

Even a simple, superficial, ordinary request may well be an attempt at (unconscious) communication from the patient and this can only be determined through an analysis of that communication.

In the course of any therapy and for any practitioner it is possible to come across a situation where the patient may feel a certain relevant issue hasn’t been paid enough attention. Depending on how important such an issue is to the patient it can be expected that the unprocessed situation might get exerted (acted out) through an unexpected issue arising in regards to monetary arrangements. This would be a case of a monetary issue in its instrumental form.

Clinical approach to monetary issues

Case by Case Approach

When exploring monetary issues the therapist can use the same “case by case” approach that would be used when treating other clinical material. All monetary issues can be looked at as being patient-specific and also situation-specific. If it is found than an issue can be classified as “instrumental” then that also means that that issue holds a specific subjective meaning for the patient and as such can be interpreted as a part of the patient’s problem that the treatment was sought for.

What follows below is a hypothetical example of a monetary issue arising in the course of therapy.

Case study – Danielle

Part of Danielle’s presenting issue is the resentment she feels over how much others seem to expect from her. She feels worn down by the demands of others but she never finds the courage to tell those “others” anything about it as she thinks her problem is only about her “not being clever enough” to deal with the demands in a better way.

When first enquiring about the therapist’s fee, Danielle says to the therapist: “Your fee is all right, that kind of money is not an issue”. She agrees to pay through the therapist’s office administrator immediately after each session. However, in the course of therapy, she is often late with her payments and has to be frequently reminded of missed payments. To these reminders from the therapist she replies: “Oh, sorry, I do always have the money with me, that’s not the problem, it’s only that I sometimes simply forget to pay. But I do pay you eventually.”

Scenario A:

The therapist doesn’t explore the issue of late payments thinking the therapy is otherwise going well and the fact that Danielle sometimes forgets to pay for the session doesn’t matter that much. The therapist is also aware that Danielle often feels “pushed for performance” to a certain standard and can never relax because of it so the therapist doesn’t want to add to her burden by demanding that she follows the payment policy 100%.

As the time goes on and Danielle continues to forget her payments despite the therapist’s reminders, the therapist starts to feel annoyed about the situation. Danielle now sometimes misses a few payments in a row. However, the therapist doesn’t say anything, again not wanting to upset the course of therapy that is in his mind going quite well. He also feels it’s now too late to be bringing the issue up again as Danielle seems to have settled into eventually paying her debt and is never more that two to three sessions late in her payments. He decides he just needs to further tolerate the late payments.

Danielle is now doing quite well personally, she says, and it seems she resolved the presenting conflicts to a satisfying degree and is ready to leave her therapy. She plans to pay the four outstanding (“forgotten”) payments just after her last session. However, she forgets to do so and the therapist has to call her to remind her of the money she owes him. The situation continues for weeks with repeated phone calls from the therapist. Danielle eventually sends a cheque in but for three sessions only. The therapist can no longer be bothered chasing Danielle and decides to let go of the last payment she owes him. However, in the coming weeks and months he often remembers Danielle and the issue of the last payment.

Scenario B:

The therapist replies to Danielle:”I appreciate that you’re not late with your payments on purpose, but I would like us to look into the issue nonetheless. My impression is that you might be having difficulties remunerating my work the way we agreed. I’m wondering if that might be because you’re not that happy with your therapy, maybe you expected more from it or maybe you think I am not providing a very good service, maybe I’m missing the point of the things you tell me, or something like that.”
Danielle: “No, nothing like that… that I can think of… But it can be a hard work sitting here for an hour.”
Therapist: “What do you mean?”
Danielle: “Well, I often leave here feeling like I’ve worked very hard, like I’ve been catching up with something. Maybe I’m not clever enough for this.”
Therapist: “It sounds like you might need more time in the sessions to think about things we discuss before you may be ready to move on to the next thing.”
Danielle: “Yeah, I don’t think I always get your comments but I just move on.”
Therapist: “So, maybe your late payments might be related to this in that the late payments might be representing your resentment over how fast things are happening in therapy.”
Danielle: “Hm, never thought of it that way… but I guess it’s possible.”

As a result of this conversation Danielle realizes how often in her life she doesn’t take enough time before making decisions but all too easily goes along with what she perceives is the expectation of her environment – just like she was perceiving that her therapist wanted her to move through the issues quickly, not take the time she needed to think about the issues to a more satisfying level. In return, she does however get the praise from that same environment, a praise that she craves as means of alleviating her feelings of “not being clever enough”.

In the above example the monetary issue is used by the patient (in an unconscious way) as means of communicating to the therapist that not everything is well with the therapy process.

When the therapist in the “Scenario A” doesn’t recognize Danielle’s need to have enough time in the sessions to work through the issues herself (without hastily moving on) and then further ignores addressing the issues of the late payments, Danielle is likely to leave therapy not fully addressing or understanding the underlying issues of her presenting conflict. This could happen despite the therapy sessions seemingly going fine.

In other words, in the “Scenario A”, the therapist is contributing to the re-enactment of the patient’s conflictual situation.

It may be worth stressing here that not all is lost if the presented psychic conflict gets partly re-enacted with the therapist through a monetary issue. Sensitive attendance to any monetary communication and the appropriate use of interpretation (as in the “Scenario B” above) even if addressed long after it has (first) occurred can get things back on track and promote development of trust from the patient.

Ways of addressing monetary issues

Generally speaking, issues around money are very sensitive for any patient. It is therefore important to address those issues in a way that is appropriate to the situation and the patient.

Monetary issues can be addressed in three different ways:

1. Management
In certain situations it might be too destructive for the therapy process to explore the monetary dynamic with the patient. However, that dynamic can be analysed through reflection or supervision and the findings may be presented to the patient in a form of an appropriate request.

Such an intervention is warranted when an assessment is made that:

a) there is not enough emotional maturity in the patient to be able to take the interpretation as only a possibility, but that the patient would likely take the interpretation to be a fact and/or a judgement about herself
b) the patient’s Self-strength isn’t sufficient for any two-way exploration with the therapist

A contra-indication would be that the patient would experience an interpretation as an intrusion.

In the above case example, the therapist may simply say to Danielle that he is not completely comfortable not being sure if she is going to remember to pay after the session and would like her to start paying just before the session, and also that the session could start only once the fee has been paid. If Danielle still forgets to pay, she can do so by using the time out of the (beginning) of the session, so the issue is still contained within the session hour even though it is not discussed about. While possibly at first the patient may be at odds about such a request, eventually the patient is likely to appreciate the therapist’s openness about wanting the initial agreement to be honoured and likely to appreciate the therapist’s firmness around that policy.

In time, the patient may be in a position to talk about the money-issue with the therapist in terms of its meaning.

2. Interpretation
In certain other situations it may be best to only make an interpretation of the situation, but without forcing a further conversation and also without making any requests for a behavioural change. E.g. the therapist may say to Danielle: “Being late with payments can sometimes indicate that the patient may be a bit resentful of the therapy or of the therapist. I’m not sure if that is the case with you, though.”

Such an intervention is warranted when an assessment is made that:

c) there is enough emotional maturity in the patient to be able to take the suggestion as only a possibility, not a fact and/or a judgement about herself
d) the patient’s Self-strength is not sufficient for further two-way exploration with the therapist

A contra-indication for this approach would be that the patient would have a negative response if she was presented only with a request for a different behaviour with no explanation given about the psychological meaning of that request, and that she would also have a negative response if challenged to make comments on the therapist’s interpretation.
In time the patient may be able to more comfortably contribute her thoughts about the given interpretation.

3. Exploration
Finally, there are situations when it is absolutely necessary to “work in the relationship” and addressing monetary questions through exploration and interpretation with the patient of what they might mean for the patient-therapist relationship equals good therapeutic work. Such is the above “Scenario B” in case of Danielle.

Such an intervention is warranted when an assessment is made that:

e) there is enough emotional maturity in the patient to be able to take the suggestion as only a possibility, not a fact and/or a judgement about herself
f) the patient’s Self-strength is sufficient for a two-way exploration with the therapist

In this instance a contra-indication would be that making single-sided requests without the accompanying exploration/interpretation and without making room for the patient’s thoughts about it may promote feelings of mistrust and so be detrimental to the therapy process.

Financial arrangements and therapy process duration

With long-term therapy, a patient’s financial circumstances may change over time, for better or worse. The circumstances may change as a result of: loss of a job, new employment, marriage break-up, moving in with a new partner, pregnancy, etc. As a consequence a patient may start behaving differently in regards to his/her payment arrangements and change his/her views on the therapist’s monetary policies.

Because a change in external financial circumstances can be interpreted as an objective change, this may take the therapist’s mind away from the concept of the instrumentality of monetary issues. However, the instrumentality is intrinsically linked only to the perceived meaning of the changed financial circumstances, so it is only through the exploration of that meaning that these “objective” changes can be fully appreciated in terms of their possible influence on the therapy process.

In the view of pre-empting any possible influences on the therapeutic frame due to the changed financial circumstances, the meaning of any such change can be explored as soon as it is learnt about.

Three months into the therapy, Brenda is excited about the marriage proposal she got, especially as her presenting problem is a history of unsuccessful intimate relationships. She talks of a rather large “perfect” celebration she wants to throw to mark the occasion. The therapist is a little envious that Brenda wants to spend all her savings on the celebration but doesn’t think much of it. A few months later, after being married for a while, Brenda asks the therapist to change his cancellation policy as, as she explains, she has an unemployed husband now to take care of financially and she can no longer afford to pay for missed appointments (as per the previous arrangement). The appointments she misses only occasionally and only due to her busy and sometimes unpredictable work-schedule. The therapist sees this as a legitimate and understandable request due to Brenda’s changed financial circumstances and agrees to alter his cancellation policy without any discussion.

Not addressing the meaning of a change in patient’s financial circumstances and its implications for therapy carries a risk of the therapist being collusive with the patient’s unhealthy traits. In the case of Brenda the therapist may be colluding with her expectation that being married is going to be only an all-exciting experience. As he agrees to alter his cancellation policy it “helps” prolong Brenda’s unrealistic expectation. Her request may be seen as instrumental but the therapist doesn’t recognize it that way.

In another scenario, John is facing redundancy in three months’ time and says financially he may not be able to continue his weekly therapy before he can find a new job. The therapist experiences John as quite resourceful person who should not have problems eventually finding a new job and knows him as financially wealthy so rather than attributing his attitude only to the change in external circumstances the therapist interprets John’s intention to temporarily quit therapy as possibly an issue of shame of being unemployed. John replies that that may well be the case as he indeed thinks of himself as useless unless he’s very busy in a job. As they continue to talk about it in the coming weeks John becomes able to stay calmer with his feeling of shame rather than rushing into an activity attempting to mask that feeling, thus allowing more time to realistically explore his options for future employment. He recalls now how when changing jobs in the past he would jump to the first vacancy without thinking of its suitability and would often end up dissatisfied with his position. In the coming months John goes through a period of unemployment but then finds a job that suits him much better than any other he’s ever had before.

Appropriate exploration of a patient’s changed attitude due to the new financial situation promotes an understanding that a changed financial situation has an impact on person’s life only through that person’s perceived meaning of the new financial situation. In other words, the new financial situation only carries a potential for a change in the patient’s inner experience, but the direction or the extent of that change is not determined by the external event. Through addressing the change in financial circumstances in psychological terms, the patient is likely to feel empowered not to feel controlled by the external financial circumstances but to make the best possible use of the financial resources available to him/her.

Financial issues and the level of mental health

The more disturbed the patient the more destructive his/her inner conflicts (or, the stronger the identification with those conflicts). More disturbed patients are more likely to use not just words but also the issues around money as means of communicating their inner reality.

So, the more emotionally disturbed the patient the grater the chance a monetary issue may become a problem for the therapy, and also, the greater the chance that the patient may not be able to constructively talk about the issue with the therapist. This is however a matter only of a form of presentation the therapists uses for their communication (as discussed in “Ways of addressing monetary issues” chapter above).

Healthier patients have a greater level of separation from the inner conflicts and can think about them more easily without strong identifications. So, they can communicate their problems through words to a satisfactory level and therefore do not need as much to use the money-related-issues as an additional way of communicating their inner reality. These individuals are generally speaking more relaxed when it comes to discussing money.

However, any monetary dynamic to do with any patient at any time (regardless of their level of mental health) is worth addressing since the potential for unconscious communication through the money-related-issues is always there.

Again, as discussed above, sometimes the situation calls for only a management, sometimes for only an interpretation, and sometimes for an exploration of the issue.

Monetary issues and the method of fee-payment

There are different ways in which the patients may be paying for psychotherapy.

The most direct way to make payments is when the patient pays the therapist directly.

In some settings the payments are made through the therapist’s receptionist/administrator, and sometimes the therapy is paid for by the patient’s relative or a partner. In both instances, a third person is brought into the equation. The involvement of a third party complicates the situation and makes any instrumental use of money more difficult to detect and to address.

For the therapists working in an organisation the patients may be paying into the account of that organisation and the therapist is then paid wages for his/her work. Apart from that “organisation” becoming the “third party”, this situation also makes any monetary-issues that much more remote from the relationship between the patient and the therapist and therefore even more difficult to detect and address.

If an agency has a stringent policy around payments that does not necessarily mean that there would be no communication happening through means of money. In fact, that stringent policy may become a blind-spot for the communication between the therapist and the patient and the monetary issues may not be explored and discussed since they cannot be changed.

In case the payments are made directly to the therapist there can be different means of that payment. The most immediate way would be a payment by cash at the time of the appointment. Any other means of payment (such as using a cheque, eftpos, internet banking, etc.) again brings a “third party” into the equation to a degree.

Deferred payments or payments made in advance complicate things as well.

Initial discomfort of addressing financial arrangements

Psychotherapy is often, at least in the public’s eye, regarded as a service. As such, it is natural for any patient to think of money in its pragmatic form only. For a patient the question is often (at least initially) as simple as this: “The therapist provides the service, the market dictates the cost, and the patient exchanges money for the service received.” So, when exploring financial issues with the patients they may often at first be surprised at what that has to do with their therapy. They can sometimes get annoyed with the therapist for spending their valuable time discussing “irrelevant things”. The discomfort may particularly become visible when discussing cancellation and holidays policy i.e. when in a patient’s eye there is no “service provision”. However, in time the patients usually come to acknowledge their appreciation for the therapist’s thoroughness in addressing all presented issues, including any monetary issue.

This initial discomfort or surprise is not to be confused with a reaction from a patient who is at his/her present level of mental health unable to constructively discuss monetary issues (as discussed in the chapter about the level of mental health).

Monetary issues and Counter-transference

One way to address monetary issues is through the observation and use of counter-transference. Here, I refer to counter-transference in its broad definition – all perception, feelings, thoughts, etc, the therapist experiences with regards to a patient. More specifically of interest is any counter-transference the therapist experiences related to the monetary issue at hand.

In case of Danielle, in the “Scenario A” the therapist starts to feel annoyed at her repeated forgetfulness to pay for her sessions but chooses to ignore that response as being outside the therapy process. I.e. he ignores counter-transference related to the presented monetary issue as within the therapy hour everything seems to be going well. This eventually leads to somewhat negative outcome for both the patient and the therapist.

In the “Scenario B” the therapist however takes his annoyance to mean that possibly not everything is going well in therapy and initiates the exploration of the monetary issue with Danielle. This leads to a more positive outcome for both of them.

Counter-transference can be particularly useful in situations where there may be a societal expectation on the reaction to a given situation. In case of Brenda, it may be considered quite appropriate for her to feel nothing but excitement over getting married and wanting to celebrate as much as possible. However, the therapist also felt some envy of her patient spending her savings on the celebration but did not address that counter-transference. Had he done so he may have initiated a conversation that could have helped Brenda be more mindful of her expectations on what a married life might be like thus helping her reach a more realistic position on spending her savings.

In case of John the therapist has used his knowledge of the patient (and this “knowledge” can be viewed as the counter-transference) to assess weather John’s idea of quitting therapy due to redundancy would or would not be instrumental act.

The existence of counter-transference related to monetary issues is in essence a message to the therapist that he/she is missing something in the patient’s communication, i.e. that the therapy itself is not going as well as it could.

As shown above, that very counter-transference can be the right starting point in addressing the presented money issue. The “objective” particulars around any monetary issue can be left aside for the time being, while the underlying dynamic is being explored. Once all of the patient’s relevant inner reality is addressed, the particulars of the financial arrangements can be brought back into the picture. With more clarity about the meaning of the presented monetary issue, it is now possible to make the appropriate new financial arrangements (if they need to be changed at all).

Psychotherapy – the “helping profession”

One specific question around money and psychotherapy is related to the issue of psychotherapy being publicly perceived as the “helping profession”. There is a particular potential problem here and it refers to the situation where a patient may take the word “help” to mean that psychotherapy has to be easily affordable. Candidate-patients may sometimes place requests on the therapist to lower the fee to a level that’s acceptable to the patient.

Such requests can also happen later in therapy. E.g. a patient who had received inheritance and put aside the money for 6 months therapy as he had never thought he might need more time than that is at the expiry of that period in a situation where the therapy is no longer as easily affordable and so he wants the therapist to lower the fee so he (the patient) can continue the therapy.

While it is not suggested that there should be no room for negotiation over the fees or that the adjustments may not be needed in particular situations, in general it may be better to exercise caution whenever such a request is encountered. What has to be taken care of here, again, is the question weather the request from the patient may be an instrument of (unconscious) manipulation, the patient “fishing” to see how “soft” or “hard” the therapist may be.

It is difficult to imagine one could always immediately know what may be at stake with a particular request and have an immediate appropriate response, so it may be necessary to take some time to explore the request first and respond to it later. The exception is a situation where the therapeutic work is at a stage where the issue can be addressed “then and there” with the patient.

A particular new financial arrangement may or may not need to follow. Sometimes, a significant part of the therapeutic work can actually be done while negotiating fees. If the negotiation of the fee is stretched over a few sessions (along side other work) and the patient then decides that the terms are not acceptable to him or her and leaves the therapy, that time spent may be of higher quality than if the therapist would immediately agree to a lower fee without any discussion – in the view that the patient is going to stay in therapy for a longer time and therefore benefit more from it. Number of sessions alone does not determine the extent of help provided to the patient.

It is possible that a patient may find the therapist’s financial policy unacceptable from the very first session and may not be willing or able to talk about it in terms of its meaning at all. This would be a rare case, though, as patients usually show signs of appreciation for the therapist taking care and time to analyse the issue before agreeing to anything. Such attitude of care from the therapist models to the patient that it is both possible and all right to value oneself and plainly communicate that position to the other person even in the face of the fact that the situation may not work out for either party (if they are not able to reach a working-agreement).

Case study – Joanna

I was seeing Joanna in an environment where the patients pay for their sessions through the office reception and the therapist does not have an immediate involvement with the payments. The general payment policy was to “pay at the time of the appointment” but the therapists had some discretion over this policy. As a rule, the receptionist doesn’t question patients’ payments under the assumption that they are negotiated with the therapist and ultimately the therapist’s and not the receptionist’s responsibility. This is also supposed to reduce the involvement of a “third party” to a minimum.

At one point in therapy, without my knowledge, Joanna started paying for her three-times-a-week sessions a week in advance. When I learnt about it (through the receptionist) I asked the patient about it and she explained that it was for the “reasons of convenience ” only. I didn’t explore the issue any further.

At a later day, again at first unknown to me, she decided that now she would be paying for all three sessions only at the end of the week.

As I learnt about it (again through the receptionist), this sudden change in the payment habit intrigued me and I decided to talk to my patient about it. It turned out that there was a particular meaning to Joanna’s actions that was a lot deeper than just the “convenience” as it seemed at a first glance.

In the first instance – while she was paying a week in advance – she did so because she was at the time feeling quite vulnerable and needed the sessions to help her through the week. She also worried I could become unavailable to her and by paying in advance she in her mind attempted to secure my presence and availability.

However, later on in therapy, and at a point when Joanna felt I kept missing the meaning of something important that she had been telling me about, she decided my work wasn’t any longer worth as much as it used to be and paying at the end of the week was a sign of her being disgruntled with my performance. Paying late was means of devaluing therapy. Paying at the end of the week also gave Joanna an option of leaving the therapy at the end of a week without paying at all for the last three sessions and this was giving her a sense of control / power over the therapy.

So, after having worked through this seemingly superficial issue of paying for Joanna’s three-a-week sessions in advance or afterwards, and in conjunction with our previous work, she was able to better understand her need to control her environment in an attempt to have her needs met.

The issues of trust became more transparent and could be talked about in therapy and since that time Joanna became more able to stay in touch with previously avoided feelings of abandonment and hurt. She again started paying her sessions one-at-a-time.

However, for some time on, she at times felt she wanted to pay the session in advance and sometimes only afterwards. She was however open about this and initialised the talk about it herself. She wasn’t any longer hiding her payment behaviour. To both of us this clearly indicated whether she was feeling more optimistic or pessimistic about her sessions and the process of therapy.

At this point I thought there was enough clarity about what was happening in terms of her payments and that her behaviour at the time was congruent to how she was feeling about therapy – and that telling me about her payment-time for any particular session was a way of saying how she felt about therapy on that particular day.

The whole question eventually became irrelevant, as Joanna became able to speak about her feelings about the therapy a bit more and needed to act on those feelings a little less.


In psychotherapy, patients may use monetary issues as a way of communication in the same way the words would be used. For a particular therapy situation any monetary issue is always a unique contribution to that therapy process. Monetary issues hold meaning for the patient that may be just as important as any other issue brought to therapy.

When a monetary issue arises it can be approached as any other clinical material. Unless explored and addressed, some of the psychic energy from the therapist-patient field may end up being dissipated outside the conscious relationship. Patients may use monetary issues as means of acting out their inner conflicts. If a monetary issue remains analytically uncontained, the potential benefit of therapy is reduced.

One way of addressing monetary issues is the exploration of the counter-transference. As appropriate, this exploration can be done with the patient or only through the reflection and/or supervision. If explored outside the immediate relationship with the patient, the findings may be brought back to the patient in a form of an interpretation and/or a request on how to proceed with the situation.

With the view of gaining more clarity in what meaning the particular monetary arrangements may hold for the course of a particular therapy, those monetary arrangements can be reflected upon even when no immediate issue is present.

Finally, it is not suggested that the exploration of monetary issues always leads to only an insight of the underlying dynamic and its meaning while practical financial arrangements remain unchanged. Circumstances in life and in therapy do change and so the financial re-arrangements may need to be made, but it is only when the situation is emotionally non-charged that the appropriate arrangements can be made. This is referred to in the text above as a “non-instrumental” situation. Appropriate arrangements are eventually usually seen as neutral (non-instrumental and non-emotional) by the patient, as well as by the therapist. Reaching the objective of non-instrumentality of any arrangement may take several sessions or several attempts.

    Published: November 2008

Ivor Tomasevich was born in Croatia where he trained as a psychologist and Integrative Gestalt psychotherapist. In 2000 he moved to Auckland, New Zealand where he practices as a psychotherapist with a particular interest in Psychoanalytic Psychotherapy.

Ivor practices from the Apollo Centre and teaches at the Auckland University of Technology, School of Psychology.

Psychotherapy and Evidence Based Practice? – Stephen Appel

November 26, 2007

Evidence based medicine emerged as a way for medical doctors to find out what is current best clinical practice. It has been defined as:

the consientious, explicit and judicious use of current best evidence in making decsisions about the care of individual patients, based on skills which allow the doctor to evaluate both personal experience and external evidence in a systematic and objective manner. (Sackett, et al., 1997, 71)

Evidence based practice (EBP) is a descendant of evidence based medicine and it is employed in all manner of fields.

In this short paper I will elaborate two ways in which evidence based practice has come to be employed over the years. Read the rest of this entry »

Norman Mailer, psychologist – Stephen Appel

November 14, 2007

From the New York Times:

Norman Mailer, the combative, controversial and often outspoken novelist who loomed over American letters longer and larger than any writer of his generation, died on Nov. 10, 2007 at Mt. Sinai Hospital in New York. He was 84.

Like many a great novelist, Mailer was a great psychologist. It might be worth reminding readers, though, that Mailer did make the several forays into psychoanalytic theory itself. Perhaps the most ingeniously outrageous instance occurs in ‘Advertisements for Myself’. Read the rest of this entry »