Wednesday, September 16, 2015

The Squick and the Dead: Intense Countertransference and BDSM

Margie Nichols, PhD

One of the best academic papers ever written on BDSM and therapy is “Psychotherapeutic Issues with “Kinky” Clients: Yours and Their’s” by Margie Nichols, PhD in Sadomasochism:  Powerful Pleasures ed. P Klienplatz and C. Moser (2006).  In all therapies, it is important to understand your client’s feelings about you, including ‘neurotic’ or at least unrealistic or preconceived ideas about you as a person and therapist:  transference, and your similar ideas about them; countertransference.  Dr. Nichols specially warned about countertransference in this paper.  She was aware then that many therapists had no direct experience with kinky clients, and a few case studies and personal prejudices often constituted all the background therapists had for undertaking this work.
While the situation is a little better now, it is premature to conclude that this problem is solved when TASHRA can go to the American Psychological Association’s annual meeting and count 50 attendees out of the 50,000 psychologists in attendance as good session attendance.  Still, I have to feel that if you have found this blog, you are showing more interest and sophistication about treating kink than the vast majority of mental health providers.  That does not mean that you will never encounter a kinky story that brings up powerful negative feelings for you.

'Studies in Hysteria' 1885, Freud and Breur, a seminal document in the beginnings of talk therapy

There are myriad sources of countertransference.  When Sigmund Freud first recognized it 130 years ago in response to his Viennese hysterics falling in love with him, he kind of liked it.  It is not so bad having all these passionate but repressed women idolizing him.  He thought it neurotic to over-respond to this idealization, and so originally, transference came to mean any unrealistic feeling a therapist might have in response to the client.  Over time, however, clinical experience and criticism of psychotherapy suggest that there are two kinds of transference:  Feelings engendered by the particular client’s relation to the therapist, I term this ‘induced countertransference.’  My example from Freud’s work on hysteria is an example of induced counter transference.  Although Freud many mistakes as a theorist, one mistake he did not make was believing that he was just an especially lovable fellow because of all that pressured female adoration.  Insight oriented psychotherapy began when Freud searched for some systematic reason why his patients all displayed this symptom rather than crediting himself.

Franz Bayroz's (1866-1924) depiction of hysteria.  Apparently he thought it was about sexual fantasy too!

The other type, neurotic countertransference, is caused by many ideas that are not strictly speaking, neurotic, but can certainly be obstacles to understanding your client.  They include our own unmet needs, internalized social stigmatization, our participation in traditional, normative and professional power structures, good and bad prior experiences with marginalization, our own acceptance of kink, sexuality and deviance in ourselves, and our own identities.  Dr. Nichols first source of problem transference is a simple lack of knowledge about BDSM.  Assuming you have been a regular reader of this blog, and have encountered the better resources listed here, you probably have some decent starting BDSM education.  Kinky readers will have some direct experience.  But the world of kink is large and diverse.  A little knowledge, or even quite a lot of it, doesn’t mean that you won’t encounter scary or ugly things you have not known about earlier.  By way of permission to feel uncomfortable sometimes, please recall that people in the BDSM community made up this term ‘squick’ when they and others experienced extreme psychological discomfort at something they learned someone else was doing.

No matter how open-minded and sophisticated you may be about kink, you are going to encounter some uncomfortable feelings, ideas and practices.  To be disgusted by these is to be ‘squicked’.  Partly this is a consequence of the fact that kink is a kind of catch-all term for a wide diversity of practices  Of all those dimensions I identified in ‘Flavors’ and ‘More Flavors’, no single dimension is required for all activities to be considered kinky by insiders or that larger society.  Not everything deviant belongs in kink, and consent is a special boundary.  Frotteurism (rubbing up against unsuspecting people in crowded circumstances), blastophilia (the sexual preference for rape) and pedophilia are not part of BDSM.  But if you associate with the kinky for very long, you are bound to say, “How could anyone who was not pathological ever consent to THAT?”  There is no guarantee that every idea in the kinky canon is healthy, but if you hang around for long, you will at least consider that there is not only more to heaven and earth, but more to health than was dreamt of in your philosophy, Horatio!

David Finkelhor, leading researcher on child physical and sexual abuse.  Another reason to doubt child abuse as a cause of BDSM sex preference:  in the last 2) years, child abuse, and all violent crime, have been headed down cross nationally.  BDSM affiliation has increased during that period.

A symptom of this discomfort with kink is the persistence of the perennial question that I keep fielding in professional meetings about kink and abuse.  “Isn’t it true that most people into kink are physically or sexually abused as children?”  In so far as an idea like this can be dispelled by mere data alone, the best evidence of several good studies is ‘no.’ But such an idea is extraordinarily difficult to disprove by data.  Starting with David Finkelhor’s “Sourcebook on Child Sexual Abuse (1986) just how much sex abuse goes on is highly dependent on how you ask the question and of whom you ask it.  But when you ask everyone the same way, whether in self-selected studies such as P. Cross and K. Matheson, or A. Wismeijer et A. Van Assen. or in well conducted surveys like J Richter et al, people who report engaging in kinky behaviors do not show more evidence of psychopathology on simple global tests of mental health.  Neither do they have higher incidence of past abusive experiences.  Although the best estimates of abuse are quite high in the general population, abuse in the population of sadomasochists is not higher.  There just isn’t any increased of prevalence of prior abuse in the kink community to be explained.  It is obvious from case reports that some people into kink were motivated to adult behaviors by childhood abuse, and that kink is part of their coping strategies for dealing with a part of that history.  Some of those coping strategies work better than others.  So nothing prevents such a person from presenting for treatment with complaint about prior abuse.  Indeed, they are more likely to come in for treatment than people who are fine with their kinks, a likely source of mental health professionals’ longstanding habit of over-pathologizing kinky people.  The people we see are more likely to be unhappy about something.

The Crucifixion by El Greco (1541-1615)  Potentially disturbing religious material
Even where there is no clear historical relationship of abuse, it is impossible for clients to live in a hermetically sealed world devoid of disturbing and even traumatic events.  Religious stories, media and entertainment, and current events are all potential sources of frightening ideas.  A percentage of kinky folk are deliberately ‘playing’ with these events and ideas.  In so far as we as therapists are disturbed by racism, abusive power plays, sex discrimination, violence, severe illness and loss, death itself, and extremes of power imbalance, it is inevitable that we will be tempted to judgment about their manifestation in clients’ sexual behaviors.  Indeed, a strong case can be made that those sexually abused people who are also into kink are more likely than the non-abused to enter into treatment.  So clinicians might be able to say from experienced that lots of kinksters were mistreated in their youth.  We have no good statistics for whether the kinky population of those in therapy and the non-kinky clients have similar rates of abuse, the most direct test of whether clinicians’ perceptions tell us about differential rates of abuse.

The propensity to be squicked by people’s sex interests is partly a reflection of everyone’s permeability to sex negativity and stigmatization in the larger society of which BDSM is a subculture.  While they may be used to such judgment by outsiders, kinksters, too, are tempted to have such judgments in the scene.  Someone’s pain looks too intense, or socialization regarding cleanliness, disease, or risk is too strong, the psychological associations too intense for them not to say “I don’t want any part of that!”  In so far as some people are sexualizing frightening material in order to manage their feelings about it, they might be hard to empathize with for those of us who haven’t mastered that skill.  If we are still afraid and can’t use sexual excitement to master our fear, we are more afraid than they are, even though they may be going to extreme lengths to master their fears.
This has several implications for treatment.  The first is that we must check to see if their sense of dysfunction about a kink or practice really matches ours, or whether we are laying our judgments on them.  Margie Nichols said exactly this 9 years ago.  Are they better served by modifying a sexy but ambivalent behavior, or striving to accept it?  How much should outsiders’ opinions count?  Such determinations can become very difficult when clients deliberately make decisions or take risks we as therapists would not take.  But even when clients’ perceptions are gratifyingly similar to our own, our intense reaction to a kink may seduce us to over react to it.

A second implication is there are some problems, some clients, and some practices for which we are not the best professional to deliver treatment.  It is wise, and can be quite uncomfortable to know our own limits.  Particular care needs to be taken when we are tempted to decide that we need to substitute our limits for our clients’.  Even when clients have explicitly contracted with us for this service, it is important to check whether the repeated need to do this is coming from us or from them, and whether it is therapeutically effective to do so.  But there is no shame in admitting that you are too judgmental about sexual health to treat bareback riding (the practice of having unprotected intercourse with partners known to be HIV positive), too disturbed by the Holocaust to treat Nazi play, or too repulsed by America’s history of black slavery to treat race play.  It is not that each of these practices is ‘healthy.’  For some who do them, they are not.  But a therapeutic relationship cannot be achieved by substituting your judgements for the clients without their explicit consent.  Furthermore, social stigma and even law privilege our judgments as therapists relative to those of some kinky practices that such consent is very difficult to obtain freely. 
Some of these factors can be dispelled by data.  I once observed a very heated professional debate about coprophila, in which half of the discussants hotly contested that such behavior was psychopathologically unhealthy by definition because of the risks associated with digestive bacteria getting into other systems.  There is indeed good evidence that some cloacal bacteria can cause UTI’s and vaginal infections, sepsis and even death if they get into the wrong systems.  Other practitioners argued that, despite the real dangers, coprophiles were not getting hospitalized in droves and that fecal play’s real risks were manageable, and the opposing clinicians were selectively reading the data because of conventional social disgust.  While both sides of this argument cited accurate data, it is probably true that only the individual clinicians involved could decide whether their own countertransference was biasing their individual readings of the data.  It is fair to say that if one is hung up on such questions, it is substituting for understanding the client in their own terms.  As a clinician, you do not need to agree with clients’ perceptions, but you must allow yourself to hear them in the clients’ terms.

It is extremely unlikely that most clients will tell you about practices that they imagine might squick you until they have established substantial trust.  That is often the most important meaning of a client bringing in a disturbing story; they trusted you to listen to it empathetically.  Like mayfly infestations that cover lakeside properties with dead bugs, they may be messy and uncomfortable, but they are a sign of a strong therapeutic process.  Mayflies are among the first casualties when water becomes polluted, they don’t spawn in large numbers and make a mess.   Clients usually won’t share stories if they don’t feel safe in treatment.

Not all uncomfortable stories are a positive sign in treatment.  In my personal experience, people who tell you such things very early in treatment are either so unempathetic that they do not recognize your reaction it, or are deliberately manipulating you in some way.  If they lack social skills, thought should be given to autism spectrum and social skills deficits and those effects on their sexuality.  Alternatively, such behavior may reflect ‘acting in’ in the treatment in which they are enacting a sadistic or controlling dynamic with you that is troubling in their relationships outside of treatment, too.
This is a huge difference between therapy and BDSM play.  Where enacting scenarios in BDSM can be sexy, fun, and reduce anxiety; all potentially ‘therapeutic’ benefits, they do not necessarily lead to change.  That is generally not a problem in play, where satisfaction is the primary goal and any change is usually secondary. Enacting such dynamics in therapy is generally an obstacle to the therapeutic changes you contract with clients to make, and the hard work, increased anxiety, and withholding of gratification that sometimes are needed for insight and change don’t feel at all pleasant.  This is the basis for many clinical complaints in the history of talking therapy about ‘perversions’ being difficult to treat.  Acting out is thought to substitute for the insight and tolerance of affects and delayed gratification needed for change.  It would do well to remember at such points in treatment that all psychological defenses are also adaptations, sources of both strengths and weaknesses.  Defenses are not such a bad thing.  It is good practice to ask about your clients’ uncomfortable stories, their feelings in sharing them, and their ideas about how you might hear them.  If a client is telling them to make you uncomfortable, it is usually an advantage to surface that in therapy and see what they are accomplishing in doing this.
A gas station infested during a mayfly die off.  Apologies to those squicked by dead insects.
The water quality is good, though!
In order to raise such questions, it is necessary to get comfortable with kinky material first.

Citations for this post included in the following post:  'What if you get squicked?'

2015, Russell J Stambaugh, Ann Arbor, MI, All rights reserved.

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