‘Therapy is at its core an intimate relationship which explores some of the most profound questions we have to encounter as human beings’ (Orbach, 1999, p. 1). Some argue that the presence of Eros in the therapeutic relationship has been ignored for too long (Clarkson, 2003a; Gerrard, 1996; Mann, 1997), and it remains an issue that many find uncomfortable and even taboo. Notwithstanding this, 73% of practitioners reported clients expressing sexual attraction for them and 90% have reported sexual attraction for a client (Pope & Tabachnick, 1993). The pervasive view that this is detrimental to therapeutic outcome probably dates from the case of Anna O (Freud & Breuer, 1895), in which Freud considered erotic attraction to be a form of resistance to treatment. The corresponding countertransference was considered in more damming light – as unanalyzed aspects of the therapist (Freud, 1915). Recently, Target (2007) argues that contemporary approaches in psychotherapy have moderated the centrality of drive theory and sexuality in the aetiology of psychological disturbance, replacing them with concepts of relational conflict and deficit. Discussion of the erotic in this context is more about the use of sexuality as a defence against narcissistic wounds. Nevertheless, psychoanalytic theories of sexuality and erotic transference phenomena have overshadowed views of the humanistic and integrative world, and Hargaden and Sills (2002) argue that humanistic critique has resulted in an equally inappropriate denial of the deep meaning of the erotic in therapy and, in contrarian fashion, declare, ‘the erotic contains within it the archetype of the universal striving for wholeness’ (p. 84). Jung noted this symbolic meaning in his linking of this striving with the alchemical metaphor and the erotic depiction of the transference relationship in the Rosarium Philosophorum (Jung, 1969).

Can the erotic be acknowledged without overt psychoanalytic theorizing or without it becoming so symbolic that the therapeutic relationship becomes desexualized completely (Renn, 2013)? When asked to give an integrative perspective, I feared the prospect of trying to develop one. I consider psychotherapy integration a personal process rather than a position or end point. I therefore needed a framework that expressed the concept of ‘integrating’ rather than ‘integrative’. I decided Clarkson’s (2003b) five-mode approach to relationship might elucidate how sexual attraction and the erotic can be explained or understood from a nondoctrinaire and integrating perspective.

Clarkson’s approach is a framework for integration rather than a model of integrative therapy that posits a pluralistic view of the therapeutic relationship based on the discourse repertoires of a wide range of therapeutic approaches. These repertoires are the working alliance, the transferential relationship, the reparative or developmentally needed relationship, the person-to-person relationship, and the transpersonal relationship. The strength of this framework lies ‘in the articulation and layering of many different theoretical angles’ (Hawke, 1996, p. 406), which allow for different priorities and emphasis. Although the erotic could be seen as a sixth mode, the lack of professional discourse about its positive qualities excludes it from the repertoire of relational possibilities that contribute to healing. Notwithstanding this, I think it is possible to demonstrate that Clarkson’s framework can help elucidate erotic attraction in therapy and focus the associated imperatives, admonitions and values. The five modalities ‘are not developmental stages but states … often subtly “overlapping”, in and between which a client construes his or her unique experience’ (Clarkson, 2003b, p. xxi). I review each modality and use them to elucidate vignettes of Eros in the therapeutic relationship I have experienced as a psychotherapist and/or supervisor. By this, I hope to identify the skills and insights that constitute good management of sexual attraction in the therapeutic relationship, and I have offered some specific interventions at the end of each section that might be appropriate to each modality.

The Working Alliance

This is the bond that enables a client and a therapist to work together, ‘even when the patient or client experiences some desires to the contrary’ (Clarkson, 2003b, p. 35). It contains the contractual arrangements concerning competencies and boundaries, attendance and cooperation, and, occasionally, to control destructive behaviours (Stuart, 2010). The parties are ‘joined together in a shared enterprise, each making his or her contribution to the work’ (Gelso & Carter, 1985, p. 163), and it should be free of ulterior motives that would jeopardize beneficial outcome. Bugental (1987) writes, ‘the therapeutic alliance is the powerful joining of forces which energises and supports the long, difficult and frequently painful work of life-changing psychotherapy’ (p. 49). Gerrard (1996) argues that such a powerful joining of forces can only happen ‘when a patient can arouse our deepest loving feelings (not empathy)’ (p. 163). She connects primary love and infantile eroticism with the more mature secondary love and sexual arousal of adulthood, and is emphatic that both are present in loving relationships. Mann (1997) asserts, ‘the erotic pervades all psychoanalytic encounters and is largely a positive and transformational process’ (p. 1), placing the erotic firmly within the working alliance. In contrast, Rogers (1951) describes a rather pragmatic approach when a client expressed her wish to have sex (p. 211). While expressing understanding of the client’s desire, the counsellor simply declined. Berne (1973) is equally straightforward when referring to sexual games as a means of gaining social and existential advantage over others. There is no sense of the erotic representing a powerful joining of forces or of it having the ‘transcendent quality’ that Kernberg (1992, p. 279) and other psychoanalytic writers expound.

These definitions confirm the omnipresence of the working alliance – it is not just the contract but the ongoing cooperation and management of the relationship by both parties. Whatever the view of sexual attraction theoretically, imperatives of the working alliance demand that it be managed for the benefit of the client, and professional ethical codes expect this. Sexual attraction, either way, must not be enacted as this constitutes misunderstanding of the roles tantamount to that raised by Ferenczi (1949) in the ‘Confusion of the Tongues between the Adults and the Child’. The reaction to a client’s overt sexual attraction may be, on the one hand, feelings of being appreciated, special, flattered or, on the other hand, feeling under threat, mistaken or insulted. The client may have similar reactions to such attention from the therapist. Neither of these extremes can be engaged, but the ‘good enough’ alliance will allow empathic recognition of the client’s feelings without inducing further regression that might lead to obsessive eroticism or damaging shame. Striking this balance is a delicate process.

A middle-aged woman was referred for depression associated with the death of her estranged partner some years before. Betty felt ‘weighed down’ by the guilt of separating prior to his death. She reported having had violent parents, and all her life she ‘had chosen passive men’ unlikely to be aggressive and felt devoid of support throughout life. She blamed herself for all her misfortune and described herself as intolerant and harsh like her mother.

About session six, she expressed interest in my personal situation and asked what I was doing over the holiday. She said, ‘you remind me of someone’, thought I might be a Buddhist and worried about her teenage son not having good male role models in his life. I felt idealized and flattered, and later she asked if I would meet her for coffee. She proclaimed, ‘I want to help others and I have a streak of goodness in me’, and I sensed a strong identification with me as she said, ‘I wish I had your insight’. I felt she was seeking a supportive father and a partner that could fulfil her needs. This attraction supported the working alliance as it encouraged attendance and gave potency to my interventions. Nevertheless, I felt fragility in the relationship – perhaps like that with her father.

I decided to confront the idealization while affirming Betty’s feelings as normal given the intense nature of therapeutic encounters. I was aware of how ‘stupid’ her father made her feel as a child and wanted to avoid repeating the trauma. I disclosed that I had a sense of her attraction for me and expressed how I valued her honesty in expressing and sharing her feelings. We discussed how her feelings related to the material she was bringing and how I complemented her childhood need for supportive and understanding parents and her desire for a new partner and role model for her son. As I declined social contact, she recognized my role as bringing her this insight and to support her mourning of these desires rather than erroneously fulfilling them. I affirmed that far from being stupid, her desire represented the very core of the work and that acknowledging it, and understanding its meaning, although anxiety provoking, was essentially the working alliance we agreed. Three key interventions are important in this relational mode:

• Value the client’s integrity in expressing their feelings
  
• Validate the client for complying with the spirit of the working alliance
  
• Verbalize how risking such expression of feelings strengthens the therapeutic relationship and trust.

The Transferential Relationship

The transferential relationship is probably the modality most written about in regard to sexual attraction. It has its theoretical base in psychoanalysis, and Freud (1905) first defined transference as a process ‘in which a whole series of psychological experiences are revived, not as belonging to the past, but as applying to the person of the physician at the moment’ (p. 116). The physician may respond with attitudes related to their past or evoked by the transference – the countertransference (Clarkson & Nuttall, 2000). ‘Transference is everywhere and unavoidable’ (Clarkson, 2003b, p. 79) and leads to unwarranted and inappropriate interpersonal attribution that can interfere with the working alliance. Transference experiences are revived, usually early familial and relational paradigms that were unrequited and laden with anxiety and ambivalent feelings. As adults we might unconsciously construe or engineer life events to symbolically represent these early situations so that they might be resolved or relived as familiar attitudes in highly anxious situations – a phenomenon known as the ‘compulsion to repeat’.

McDougall (1995) asserts that ‘Human sexuality is inherently traumatic’ (p. ix) and ‘profound ambivalence complicates the attachment and attraction to our parents’ (original italics, p. xiv), who constitute our first love objects. Laplanche (1995) further elaborates that psychosexual attraction is derived from converted frustration at the loss of the object, which is then a sought-after fantasy that in reality cannot be refound. Target (2007) suggests that such innocuous frustration can be inadvertently eroticized by the caregiver, while actual infant sexual excitement is usually unacknowledged, uncontained or even shunned. The result is a ‘psychosexual core which is unstable, elusive and never felt to be really owned’ (p. 517) and adult sexual relations are posited as a means of stabilizing this elusive core. Klein (1997) described this scenario in the ‘Origins of Transference’, where ‘the infant has from the beginning of post-natal life a relation to the mother which is imbued with the fundamental elements of … love, hatred, phantasies, anxieties and defences’ (p. 49). This has implications for sexual attraction in therapy where a balance between being a sought-after fantasy or an uncontaining object needs to be managed.

Richard, a young gay man, was HIV positive and referred to a much older gay therapist by a befriending agency. He was acutely distressed and wanted to explore his childhood, his promiscuity and aggression in relationships, and his feelings of worthlessness. As a child, he suffered parental physical abuse, especially from his father. His mother could also be ‘grotesquely angry’ and would report his bad behaviour to his father. In his teens, he would go cottaging and met an older man with whom he had regular ‘sexual, but loving relations’. He said sadly, ‘I just wanted some love’. His depression related to his unhappy childhood and, following infection, his precarious future. As his blood results worsened, he faced anxious decisions about drug therapy, which evoked ‘the return of the bad object’ (Fairbairn, 1952; Nuttall, 1998). He felt ‘knocked down’ by HIV and, taking on the burden of badness, he said in tears, ‘I feel as though I’ve failed; the virus is the ultimate failure. I’ve always failed; at relationships, job – a sorry pathetic life really. Whenever I get things together, I spoil it’.

Richard was a handsome and pleasant young man. He mitigated his badness by being ‘a perfectly presented package’, polite, well mannered and charming, just as his mother demanded of him as a child. He was highly seductive and increasingly attractive to the therapist, who reported to me, his supervisor, the desire to ‘give him a blow-job’ as he sat opposite with open legs. This was reflected in the transference, as Richard said, ‘being here for this hour is the safest place to be’, and asked the therapist to be his mentor. Challenge to this mitigating defence such as feeling belittled at work, poor blood results or a simple rebuke evoked rage that destroyed any goodness and left him feeling depressed and unloved. The therapist felt wary about making interpretations for fear of provoking an angry reaction, and to reflect the client’s underlying desire for emotional contact seemed potentially seductive and submissive. The therapist judged it best to avoid reference to such desires as they might constitute a defence against deeper issues – such as loss, dread, anger, hope (and ultimately longing) of the kind Klein and Laplanche refer to.

However, this avoidance led to some undesirable acting out. As the erotic transference was at its height, the client attended with little to say interspersed with periods of silence and sulking. As this seemed purposeful, the therapist raised his own sense of being excluded from something. The client responded that ‘because you’re not gay you won’t understand’ and said he saw the therapist ‘as an authority figure’ and ‘someone I shouldn’t upset’. Soon after the client admitted his sexual involvement with an agency worker and was anxious about the therapist’s reaction – the client feared the therapy might be terminated.

This questions what can be reparative in such highly cathected contexts and is an issue associated with counselling in gay befriending settings. Much depends on the therapist’s experience and judgement of how concrete the client’s thinking is with respect to the treatment process. The therapist’s judgement seemed sound, notwithstanding the seductive nature of the client and the weakness of the worker. However, this vignette raises the issue of what kind of intervention would avoid enactment in the transferential relationship, and the following are probably the general aspects to bear in mind:

• Acknowledge the client’s anxiety about having feelings of attraction.
  
• Relate the feelings to the broader issues being raised in the therapy.
  
• Link the relational pattern with other relationships in the client’s life and explain the transference process.