The Vault

Good Fences Make Good Neighbours

By John T. Maltsberger, M. D.

 

Ladies and Gentlemen—Alexander work, the medical examination, a psychiatric interview, consultation with a psychologist, social worker, or lawyer, and, generally speaking, the encounter between a student and a teacher are all similar in certain important respects. 

In each instance there is an underlying presumption that one of the parties has a special knowledge, skill, or perspective that the other does not, and that such gifts will be exercised for the benefit of the person who comes for help, treatment, advice, or education. The relationship between the two is therefore unequal, it presumes an attitude of trust and hope in the patient, student, or client, that the person in authority will exercise his special capacities for the benefit of the other. Furthermore, there is almost always a presumption of privacy and confidentiality, and there is usually the offering of a fee. 

All such relationships are fiducial—a fiduciary relationship is one predicated on faith and trust. That I as a psychiatrist and psychoanalyst have been invited to address your congress is not because I have any special knowledge or grasp of the Alexander Technique, although I have for some months been an Alexander student myself. Rather it is because like an Alexander teacher I am an experienced fiduciary. For a good many years I have practised psychiatry and psychoanalysis. Your program committee invited me here hoping that some of the experience and perspective of my discipline may be helpful to you in your own. They hope that what I may have to say will offer some perspective now that in so many areas of the world you are systematically organizing and striving to clarify professional standards. So I address you as an Alexander friend from a different but in some respects parallel profession. We have much in common. I will limit what I have to say today to the subject of professional boundaries, although there is much else we could take up together. 

Robert Frost said, “Something there is that doesn’t love a wall, that wants it down.” The therapeutic action of psychoanalysis depends on the systematic breaking down of a specific boundary, that of the block in communication which ordinarily operates between people—the barrier against saying absolutely everything which comes to mind. Setting this barrier aside is essential for ‘free association.’

Because of our experience with free association we analysts are permitted a view into the minds of others that is seldom possible elsewhere—even in the most intimate relationships people do not (better not) disclose everything that comes to mind. Through the window of free association we have learned to appreciate certain phenomena that are not unique to the psychoanalytic encounter, but to some degree operate in all fiduciary relationships. One of these we call transference.

Transference is “the displacement of patterns of feelings and behavior, originally experienced with significant figures of one’s childhood, to individuals in one’s current relationships.’ It is an unconscious process, and therefore spontaneous and unplanned. It usually appears in psychoanalytic work gradually, although sometimes it jumps out at you suddenly, even explosively. Because our patients are systematically encouraged to tell everything, we hear about it as it appears, although indirectly at first.

It is a strange experience sometimes to find yourself being treated as though you were explicitly somebody else. Ordinary patients think it strange, too, when the phenomenon is drawn to their attention. Sometimes they find it painful and embarrassing, especially when there is an erotic component to it, as there very generally will be. They can see that they are imposing something from their own minds on the analyst that really has nothing to do with him. Some common attitudes our patients develop in the transference are idealization, love, dependency, longing for approval, fear of disapproval, and intolerance for separations, as at vacation times. If the transference has a more negative color, we may be experienced as critical, cruel, cold, contemptuous.

Transferences usually have a mixture of negative and positive features, though we hope for a preponderance of the positive. Our patients when in the grips of transference tend to relate to us as children might, and from this arises many jokes and cartoons—more recently, even novels and cinemas. Of course transference is not something that happens only in the course of psychoanalytic treatment, although the analyst’s interfering with the inhibition against telling everything that comes to mind assuredly enhances it. It is an element in every relationship, although usually it is not terribly intense, and it remains unconscious. It is likely to become much more intense in fiducial relationships, because these parallel parent-child relationships, and they are to a greater or lesser extent, unequal. Eruptions of transference feelings are common between clergymen and parishioners, between university professors and students, and, I understand, they are familiar to Alexander teachers.

Alexander teachers have told me that sudden eruptions of tears, sticky clinging behavior, seemingly inexplicable angry outbursts, and odd erotic reactions are quite familiar in the course of their work. Ordinarily it is possible to deal with such phenomena by setting them aside, gently but firmly, although sometimes they lead to interruption of the teaching relationship. Also familiar to you are those peculiar resistances to accepting Alexander direction, consisting often in seemingly stubborn adherence to former patterns of use, refusals to release, or what have you. Inasmuch as free association is not part of Alexander work, insight into the transference nature of these phenomena is not usually direct, although psychologically sophisticated, sensitive teachers can often guess quite correctly what is going on. 

I hope that the future will bring psychoanalysis and Alexander work closer. We have much to learn about the integration of use with unconscious mental experiences in adult life and across the span of child development. Before the development of the Alexander Technique no method opened the way to study how the flow of neuromuscular use might correlate with the flow of mental associations and the emotions which accompany them. To the best of my knowledge there is as yet no investigation in which a person has been asked to free associate in the context of Alexander direction so that the dynamic integration of mental and neuromuscular use could be observed. 

Though transference remains hidden from you in ordinary Alexander encounters, it is silently present in the work. Transference must also be an important if unspoken consideration in your training schools, where the contact between Alexander faculty and student-teachers is so very much more intense. All of you will be aware that extraordinarily intense feelings may emerge in the course of your training as teachers, and that part of your professional development is integrating and mastering them. Although I have no personal data to support my claim, I presume that just as the psychoanalytic adjuration to give up the usual inhibitions against totally free communication invites transference, so does the Alexander Technique’s effort to dissolve old blocks against integrated use. Alexander work tries to show students a new way for body use, and sometimes, a new way of perceiving the surrounding world, through explanation and the teacher’s hands. How very like the good experiences of early childhood Alexander teaching is. How inviting the work therefore must be to experience the Alexander teacher as a helpful, loving parent. 

I would further suggest to you that the hands-on experience of Alexander work, involving as it does physical proximity, skin and olfactory stimulation, is likely to be sexually arousing, only to a minor extent in most students, but intensely so in a few. And just as psychoanalysts sometimes react erotically to what they hear from the couch, so must Alexander teachers sometimes react similarly when they stand close to certain students and touch them. Some patients may arouse hateful responses in the analyst. We have learned to look for such responses in ourselves and to study them as valuable indications of what transpires, or what tends to transpire, in the therapeutic relationship. We do not act on them, and, most of the time, we do not ordinarily tell our patients about them. But they can help us understand what is going on, and inform our therapeutic interventions. It may be that a heightened alertness to the teacher’s more shadowy emotional responses to students can help in Alexander work as it helps us in psychoanalysis. 

Most of the time transference responses in psychoanalytic work, and in Alexander work, do not give rise to trouble. In fact, the positive ones do much good if they are not too intense. When the transference is loving (but not erotic), hopeful and trusting, learning is accelerated. Does anybody ever really learn anything outside a context of love and trust? We welcome positive transferences of this sort early on—they often indicate a successful treatment will develop. Both the analyst and the patient, the teacher and the student, are usually able to keep a balanced perspective and to recognize that the various kinds of unruly emotional responses which occur do not belong to the work at hand. I believeAlexander people do this instinctively, out of common sense, but that you do not much think about it. In analysis, these responses can become the focus of the therapeutic effort. In Alexander work, I understand that they are generally gently but firmly set aside and in general go undiscussed. All the while we get on with our work, setting selected boundaries aside in order to encourage the surrender of old stultifying uses. We get close enough to our clients to identify empathically with them—close enough to experience through temporary identification with them something of their habits of reaction so that we can devise corrective interventions, moment by moment, through interpretation and clarification in one kind of work, through direction in the other. 

We maintain most boundaries but we surrender others. But it is a necessary vicissitude both of psychoanalysis and of Alexander work that the necessary loosening of some boundaries invites the crossing over of others. 

The results of crossing the wrong boundary can be disastrous. When the essential terms of the fiducial relationship are trespassed upon, the purposes of the collaboration are changed, and trouble often follows. The essential boundaries, those never to be crossed are these: the fiduciary, or the person to whom the welfare of the client is entrusted, must act only for the benefit of the client, and, apart from the fee, must ask for no gratification of his own needs. We must neither punish nor seduce, and we must not respond to punishment or seduction in damaging ways. 

We in psychiatry know that there are two classes of patients who are likely to have difficulty when in the grips of transference reactions. I must emphasize that for the most part we psychiatrists are sought out by a clientele quite different from yours—our patients come to us because they are in emotional difficulty. Your students come for other reasons and are less likely to be disturbed. But a few of them are sure to be emotionally ill. Ordinary students will not have special transference difficulties. But there are two kinds of possibly troublesome students I want to mention to you. The first group will suffer from psychotic illnesses, and the second, from personality disorders, but especially, from borderline personality disorders. 

Psychotic patients often have great difficulty in discriminating between what they imagine to be so and what is in fact so in their interpersonal dealings. These patients have lost an essential personality function which we all need in order to maintain appropriate, realistic balance in our relationships with others. In the jargon of my profession we say that such patients have lost the capacity for reality testing. Others may lose the capacity to discriminate where their minds leave off and the minds of others begin. Such persons may be completely convinced that they can read your thoughts and feelings, or that you can read theirs, or that through some malignant magic you insert unwelcome thoughts and impulses, often of a revolting nature, into them. They lose their capacity correctly to appreciate the indispensable boundary between their minds and ours. 

The distortions into which psychotic patients may fall are generally so global that they become obvious. For instance, in erotomania, the patient may develop a delusion that someone else, usually a person in authority, is in love with her, and behave accordingly. Others may develop persecutory delusions. Should a student develop paranoid delusions of persecution about his Alexander teacher (this will happen one day if it has not happened already) he may be convinced that the laying-on of hands is the first step in a brutal assault or a homosexual seduction. He may run out of the room if he does not physically attack the teacher. Fortunately such events are not too frequent, but they certainly occur in the course of psychiatric practice. I narrowly escaped being thrown against a wall in June, and I was sitting across the room at the time. Alexander teachers stand close. It behooves us all to get to know any new patient or new student before commencing our work, and certainly before getting close enough to touch. 

Patients with borderline personality disorders are for the most part less obviously disturbed. For this reason some time may pass before we appreciate that the patient has not only formed an intense transference, but the patient does not have the usual capacity to discern that the transference is inappropriate to the relationship, that it does not make sense, and that acting on it would be inappropriate. Borderline patients are typically very unhappy people indeed, prone to sudden, intense idealizations, and it is not unusual when they meet a new helping person for them to fall deeply into a kind of childlike love. More than one have declared to me that I am the first person they ever met who truly understood, who genuinely cared, who could really help. 

They want to get across the boundaries, to involve themselves in our personal lives, literally to become members of our families. When these longings and wishes are frustrated, the preliminary idealization will typically fall away and be replaced with an attitude of hate and resentment. The analyst then emerges in the patient’s mind as a betrayer and a Judas. These patients are impulsive. In the idealizing phase they may bring expensive gifts, ask for reassuring embraces, telephone continuously. One of them stationed herself under a tree across from my home for several days and watched all comings and goings longingly. If they get angry there may be emotional storms, suicide threats, and the like. One such patient, furious at her therapist when he went away on vacation, obtained a live tarantula, put it in a box, wrapped it up in plain brown paper, and mailed it to him. 

Because I want to make the pattern vivid in your minds I have presented a somewhat extreme picture of the borderline patient. Some patients of this kind are indeed very extreme from the beginning, but many are not. Little may be evident early in a relationship other than a certain neediness, a tendency to idealize, and perhaps, in the Alexander encounter, signals of longing to be held and comforted. You might notice a tendency in some such patients to almost hand themselves over to you physically, for many have had quite disturbed experiences of mothering in early childhood, and do not have a clear sense that their bodies are a part of themselves. They often feel that their bodies belong to others, often to their mothers. Many feel that their bodies are not real, but somehow illusory, and that they live in them as rather uncomfortable tenants. Borderline patients can be highly manipulative and will stop at nothing to get their way—their moods are unstable, they are chronically more or less miserable, and the manipulativeness is in the service of getting others to offer them comfort, soothing, and love because they are so impaired in their capacity to comfort, soothe, or love themselves. Their predominant mood is depressed, anxious, and needy. Borderline patients are notoriously intolerant of solitude for this reason. They are very likely to make suicide attempts of one kind or another, and often have been in psychiatric hospitals many times. You may have your suspicions raised if you see wrist scars suggestive of the very common tendency to self-cut. But bear in mind that many borderline patients do not have all of these characteristics in a pronounced degree, and that many, especially at first, may present themselves as quite attractive, very sensitive, and very well put together indeed.

About half the patients who bear this diagnosis have been sexually abused as children. They have had no opportunity in childhood to grow up with a mature sense of physical boundaries, therefore. Their self-esteem is low, they feel profoundly needy, and they tend to look for emotional comfort and soothing in sexual encounters that have little in common with mature erotic love. They frequently expose themselves to sexual assaults, and many will tell you stories of repeated rape. Borderline patients are furthermore often deeply intuitive. They guess at the vulnerabilities of others, and use their perceptions to get close to others, often very quickly. They tend to play upon any instability in the emotional professional balance of teacher or therapist. 

Imagine, for instance, you are a middle aged psychiatrist locked into a frustrating and unhappy marriage where most of what you get is vinegar. Your self-respect is low. Or imagine further that you are recently separated from your wife, lonely and depressed. A pretty, younger patient (most of them are women) appears in your consulting room and tells you how understanding, sensitive, and physically attractive you are. A patient in the spell of transference may be blind to the balding head, the spreading belly. Such flattery, admiration, and trust are heady stuff. It is easy for us to blind ourselves, to believe that transference love is for us, that it is the real thing, and not the product of the professional relationship and the patient’s neediness. This is especially so when we feel low and needy ourselves. As she leaves the room the patient impulsively throws her arms about your neck, kisses you, and begins to cry. Will you have the balance and the courage, firmly but kindly, to disentangle yourself and to tell her that intimacies of that kind do not belong in the relationship? If she has sexually aroused you, will you? And what if she repeats it in the next interview? 

Most of the psychiatrists who become sexually involved with their patients are probably men with emotional problems of low self esteem, loneliness, mild depression, neediness. Some of us, finding ourselves across the border, as it were, will turn to colleagues for help, extract ourselves from the inappropriate entanglement, and go forward, sadder but wiser, keeping our professional conduct inside acceptable bounds thereafter. But a certain number of us are predatory, and, when discovered, prove to have been sexually intimate with many patients over many years in a straightforwardly exploitative, cynical way. 

I am sorry to report that in a recent survey it was found that 7 per cent of male psychiatrists had been sexually involved at some time or another with patients, and about half that fraction of female psychiatrists have. The figures for American psychologists are comparable. We do not have figures for other professionals, but it is generally believed that other physicians, including gynaecologists, fairly frequently go ‘over the border,’ as do clergymen. I am not aware of any statistics of this kind for Alexander teachers. 

At the beginning of sexual relationships with patients therapists will frequently rationalize their behavior as being for the patient’s own good. They feel the poor patient needs a little affectionate encouragement. Liaisons of this sort may often begin with what appears to be a reassuring hug at the end of a session, but one thing leads to another. In psychiatry we have now concluded that these affairs are so often harmful that they must be discouraged by every means. They generate profound shame in the patients, and profound ambivalence toward the therapist, who at once is likely to be experienced as Godlike and at the same time enslaving.

The patients will often blame themselves, accusing themselves of whorish wiliness. Often the sexual relationship with the therapist repeats the experience of childhood incest and reinforces the guilt, self-loathing, and fury that derive from it. If the patient becomes disillusioned and manages to break free, or if the therapist rejects her, the patient will be left with profound feelings of depression, emptiness, and badness. Having likely come to therapy in the first place with sexual confusion and difficulties, the patient will be left worse off than before. It will be harder in future to trust those who ordinarily would be seen as trustworthy. Emotional lability will often follow, and prolonged states of rage, vengefulness, and suicidal threats are common.3 Suicide can certainly take place under such circumstances, and so can enough disorganization so that admission to a psychiatric unit is necessary. 

Professional and public awareness of this problem has been greatly heightened in the United States over the past ten years. The published ethical standards of the national associations for psychiatry, psychology, social work, and pastoral counselling all make it plain that sexual activity with a patient or client is never acceptable. In the case of psychiatry and some others the prohibition is permanent—sexual intimacy is never acceptable once a professional relationship has been established, even after the professional connection has been terminated.4 

We assume in psychiatry that a patient can never give adult, informed consent for sexual intimacy with the therapist for a variety of reasons. In the first place there is the consideration of transference, a phenomenon which fills the patient with child-like longings for love, comfort, fear of being sent away by the idealized, seemingly-omnipotent therapist who is perceived as a parent. Even when not explicit, these attitudes are likely to be there. Just as a child will do anything to gain the approval of the parents, including submission to outright incest, adult patients can be similarly influenced. Our patients are furthermore mentally or emotionally ill, and reluctant to give up a relationship which, apart from the sexual aspects, may have proven helpful. I would suggest to you that at least some Alexander students may also suffer from emotional troubles, transference reactions, and idealizing dependency which make informed consent impossible in your circumstances, just as it is in mine. But even were you to persuade me that Alexander work is so different from psychiatry that such intimate relationships are intrinsically less likely to be harmful, the teacher who permits such a development is assuredly imprudent and taking a serious risk. The tide of the times is running against it; society at large is no longer tolerant of liaisons arising in fiducial relationships. 

The psychiatrist or the Alexander teacher who becomes intimately involved with someone ‘across the border’ risks serious hurt. Most, but not all, will sooner or later have to pay for such behavior with feelings of shame and guilt for having injured someone who came trustingly hoping for help and received hurt instead. Apart from private suffering, however, is the risk of professional injury. 

For those fiduciaries whose professional codes of ethics forbid sexual intimacy with clients, crossing the boundary is not only prima facie evidence of misconduct that can lead to reprimands, suspensions, or expulsions from professional societies, but can lead to loss of licenses. Psychiatrists, as physicians, stand to lose their licenses to practice medicine in addition to suffering public disgrace for their misconduct. 

I believe that at the present time the codes of ethics for most (if not all) of the national organizations of teachers of the Alexander Technique do not address the question of sexual intimacy with students. In this they are like the American Bar Association, the American Association of University Professors, and the United States national organization for chiropractors, which do not explicitly prohibit sexual contact with clients and students. But the absence of official ethical statements against sexual intimacy in some fidicial relationships does not leave practitioners invulnerable in case it takes place. 

Chiropractors, for instance, have lost their licenses when complaints were made to state licensing boards that inappropriate forms of massage of a plainly erotic nature had been used. The same thing has happened to dentists. Lawyers have been disbarred for sexual misconduct with clients, and judges removed from the bench. 

Unlike some of the other professionals, teachers of the Alexander Technique are not yet regulated by state licensing agencies in my country, so that they would not at present risk such sanctions as loss of license or disbarment. Nevertheless they are still subject to the laws pertaining to torts. Torts are civil wrongs redress for which may be sought in the courts. Sexual harassment is a tort for which one may be sued and for which damages may be awarded, and so is battery—inappropriate touching of another person or his clothes. 

Furthermore it is quite possible for an Alexander teacher to be sued for malpractice. One can imagine a case in which a student would complain that a teacher took sexual advantage of her in the context of Alexander lessons, and that she was not in a position to give informed consent. Arguments to compare the teacher’s behavior to that of psychiatrists, physicians, and chiropractors in cases of precedent would be raised, and, given the current hostile attitude to helping professions in the United States, I would anticipate sympathy in the jury box. In the United States we even have clergy malpractice, and I see no reason why Alexander teachers would be held immune. 

Finally there is statutory law explicitly forbidding sexual intimacy in professional relationships in an increasing number of jurisdictions. In Minnesota, for instance, there is a statute forbidding sexual exploitation by psychotherapists with current or former patients. A psychotherapist is defined as a physician, psychologist, nurse, chemical dependency counsellor, social worker, clergy, or other person, whether or not licensed by the state, who performs or purports to perform psychotherapy. And psychotherapy, in turn, means the professional treatment, assessment, or counselling of a mental or emotional illness, symptom, or condition.5 Would Alexander teaching qualify under this Minnesota law? 

Finally there is the matter of criminal law. There is an increasing movement to criminalize sexual intimacy in fiducial relationships, and these laws are broad. They cast the net wide, and definition of a ‘therapist’ in these statutes in quite a few cases would probably embrace Alexander teachers. It is a criminal offense in Minnesota, Michigan, Florida, New Hampshire, North Dakota, Colorado, California, Maine and Wisconsin to go across the boundary with a patient or a client. Five other states have similar bills pending in their legislatures.6 

Let me not end on too legalistic a note. While it is necessary to respect boundaries for the protection of those who come to us hoping to better themselves and to grow, much can be learned as we study our subjective reactions to patients and students. Awareness of transferences, and of our reactions to the transferences, can guide us in our work. Erotic responses require restraint. But in my work an uncaring, cold therapist does not help patients get better. Our patients need us to care about them. I do not doubt that the same truth applies in Alexander work. We need to love in order to work effectively, but across a boundary. Let me leave you with a shortened version of Robert Frost’s poem: 

Mending Wall 

Something there is that doesn’t love a wall,

That sends the frozen-ground-swell under it,

And spills the upper boulders in the sun;

And makes gaps even two can pass abreast....

No one has seen them made or heard them made,

But at spring mending-time we find them there.

I let my neighbor know beyond the hill;

And on a day we meet to walk the line

And set the wall between us once again.

We keep the wall between us as we go....

We wear our fingers rough with handling them.

Oh, just another kind of out-door game,

One on a side. It comes to little more:

There where it is we do not need the wall:

He is all pine and I am apple orchard.

My apple trees will never get across

And eat the cones under his pines,

I tell him. He only says, “Good fences make good neighbors.”

Spring is the mischief in me, and I wonder

If I could put a notion in his head:

“Why do they make good neighbors? Isn’t it

Where there are cows? But here there are no cows.

Before I built a wall I’d ask to know

What I was walling in or walling out,

And to whom I was like to give offense.

Something there is that doesn’t love a wall,

That wants it down.” I could say “Elves” to him,

But it’s not elves exactly, and I’d rather

He said it for himself. I see him there

Bringing a stone grasped firmly by the top

In each hand, like an old-stone savage armed.

He moves in darkness as it seems to me,

Not of woods only and the shade of trees.

He will not go behind his father’s saying,

And he likes having thought of it so well

He says again, “Good fences make good neighbors.”

 

FOOTNOTES

1. Moore, Burness E., & Fine, Bernard, D., A Glossary of Psychoanalytic Terms and Concepts, New York: The American Psychoanalytic Association, 1968, p. 92 

2. Gartrell, N., Herman, J., Olarte, S., Feldstein, M.and Localio, R., (1989) “Prevalence of Psychiatrist-Patient Sexual Contact,” in Gabbard, G. 0., ed., Sexual Exploitation in Professional Relationships, Washington: The American Psychiatric Press, Inc., pp. 3-13. 

3. Pope, K S., “Therapist-Patient Sex Syndrome: A Guide for Attorneys and Subsequent Therapists to Assessing Damage.” (1989) Gabbard, G. 0., Op. cit., pp. 39-55. 

4. Please refer to: American Psychiatric Association, Principles of Medical Ethics, with Annotations Especially Applicable to Psychiatry, 1981; American Psychological Association, Ethical Principles for Psychologists, Washington, DC, 1981; National Association of Social Workers Code of Ethics, 1980; American Association of Pastoral Counsellors, Code of Ethics, 1980. 

5. Perr, I. N., “Medicolegal Aspects of Professional Sexual Exploitation,” (1989). Gabbard, G. 0, Op. cit. pp. 211-227 

6. Strasburger, L. H., Jorgenson, L., & Randles, R. (1991) “Criminalization of Psychotherapist-Patient Sex,” The American Journal of Psychiatry, 148, pp. 859-863. 


BIOGRAPHY 

Dr Maltsberger is a graduate of Havard Medical School, where he is currently Associate Psychiatrist at McLean Hospital. His major research interest is suicide, a subject on which he has published a number of books, among them— Suicide Risk: The Formulation of Clinical Judgement (New York: New York University Press, 1986).

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