There is considerable ignorance, confusion, and anxiety around the issue of sexual feelings in therapy. This leaves both patients and therapists vulnerable when such feelings do emerge - vulnerable both to acting out in sexual contact, and vulnerable to defensive avoidance against dealing with crucially important therapeutic issues.

(A) ROLE OF SEXUAL FEELINGS IN THERAPY

Patients' Sexual Feelings in Therapy like any other feelings can

1. emerge in response to aspects of the real relationship in therapy or emerge as transference reactions, i.e. as feelings displaced from earlier relationships,

2. develop in the emotionally intimate, safe relationship, perhaps the most intimate and self-disclosing relationship one has had, in which one's feelings are accepted as legitimate and important. Sexual feelings are often the most difficult feelings to be attended to in therapy,

3. emerge in the context of the therapeutic relationship in which the most intimate aspects of the self are revealed,

4. emerge in the context of a therapeutic relationship in which the therapist seems a powerful and good caretaker, (the ideal parent one always wished for)

5. easily provoke intense feelings of wanting to be loved completely, to be cared for completely, to have all one's needs met, to identify and merge with this all-powerful, all-good other; to have all one's unfulfilled dependence needs filled.

(B) PATIENT'S SEXUAL FEELINGS IN THERAPY

What is important to keep in mind is that sexual feelings experienced by patients may have multiple meanings. Until these meanings are explored, we don't know what those feelings are about, what they express about the patient's defenses, conflicts, development, communication style or needs. If a therapist acts to gratify a patient's sexual feelings, apart from all the other damage that is likely to be done, the therapeutic enterprise stops. If a therapist is made afraid or anxious by a patient's sexual feelings, and then avoids therapeutic work on them, the therapeutic enterprise can be compromised, stalemated and/or stopped. Therapists who avoid or punish patient's sexuality out of their own discomfort also do a disservice to and can be damaging to their patients.

The following are some of the meanings of sexual feelings of patients towards their therapist. Sexual feelings and wishes can arise

1. from the wish to feel attractive, wanted, admired, special, to have one's self-worth validated,

2. if sexuality has been the only kind of intimate connecting someone has known, (intimacy means sexuality),

3.` as a defense against meaningful emotional contact and intimacy in the therapy,

4. as a defense against the experience of the pain of unfulfilled needs, or as a defense against the pain of separateness,

5. as a defense against other feelings - anger, sadness, frustration, tension and anxiety,

6. in patients who are struggling to master earlier relationships, relationships which were abusive and/or sexualized, (as re-enactment and/or compulsive repetition of past traumatic relationships),

7. as an effort to control the therapeutic relationship: either to keep the therapist close (if sexuality is seen as the way to do that) or to escape the feelings of vulnerability provoked by the therapeutic relationship, keep distance, control and power in the relationship as a defense against regression and dependency needs. (e.g., this may especially occur in a relationship with a male patient and female therapist.),

8. as an expression of anger or hostility toward the therapist, an effort "to cut her or him down to size" and exercise control/power over the therapist,

9. as expressions of positive growth in a patient as a direct result of the therapy.

(C) THERAPISTS' SEXUAL FEELINGS IN THERAPY:

Can arise out of all the same needs, conflicts, and defenses patients experience - and can arise both out of features of the real relationship, out of the therapist's own transference, or in response to the patient. A therapist, like a patient, does not have to be disturbed to have such feelings. We don't know what the feelings mean until they're explored and understood.

1. Sexual feelings in the therapist can arise out of the desire to be attractive and wanted, to have one's worth validated; out of confusions or conflicts about emotional intimacy; out of needs to avoid uncomfortable feelings of sadness, or anger, or frustration, or anxiety; out of a need to feel in control; out of an attempt to master unresolved or conflicted past sexualized relationships; out of hostility.

2. For the therapist too, the therapeutic relationship is intimate, but in a different way than for the patient, i.e. it is safe - he or she is quite unexposed. The therapist also is subject to what can be a very flattering and exciting feeling of being idealized and needed.

3. The therapist may be seduced by the desire to be a gratifying object; or seduced by feeling omnipotent - "Here is a troubled and needy patient, and I can make up for all this patient's deprivations, and fill all this patient's unmet needs."

4. The therapist may be emotionally or sexually vulnerable himself or herself, may be lonely, or in a troubled relationship, a life crisis, a regressed state, or possibly may be ill.

5. The therapist may have difficulty tolerating intense feelings without acting on them.

6. The therapist may have trouble dealing with feelings of guilt for having stimulated (by encouraging verbalization) a patient's sexual feelings without gratifying them - (this may especially apply to female therapists with male patients).

7. A therapist may feel narcissistically gratified by a patient's development or growth - and fall in love with what he/she imagines is his or her own creation.

8. The therapist's sexual feelings for a patient may reflect a generalized, positive, loving response to the patient's person, or to the patient's development.

9. `A therapist's own repressed traumatic childhood may be insufficiently mastered leaving the therapist prone to collusive countertransference re-enactments with a patient who has similar dynamics and/or narcissistic vulnerabilities.

(D) CONCLUSION

The basic rule in dealing with sexual feelings and wishes in therapy is that verbalization has to be securely and safely separated from action. In practice this means that patients' verbalization of such feelings may not be an indication of the patient's readiness to work to understand the meaning of these feelings but an expression of threatening and overwhelming affective states. Patience, perseverance and therapeutic commitment to the task of therapy by the therapist are essential for building a treatment alliance, which, along with informed consent and respect for treatment boundaries, creates the safe foundation for enabling patients to integrate their sexuality into their lives.