Erotic Transfer in Borderline Personality Patients

While there has been much progress in developing effective treatments for borderline personality disorder (BPD) over the past 20 years, the areas of love and sex are not generally addressed. Transference-focused psychotherapy (TFP) attempts to make up for this gap in helping patients achieve satisfying lives.

TFP posits that the developing mind is structured around the internalization of images of self and other linked by an affect. In the course of early development, the internalized images are of an extreme nature. They are characterized by ideal loving feelings when they are associated with experiences of pleasure and satisfied needs, and they are associated with unremittingly negative, painful, fearful, and aggressive feelings when they are associated with experiences of when needs are not satisfied. Without integration of these two segments of the mind, an individual has difficulty appraising experiences accurately: the affect in the moment is the whole reality. This split structure, which is seen as characterizing individuals with BPD, has clear implications with regard to an individual’s experience of love and sexuality.

Like the rest of us, BPD patients wish to love and be loved. We should note that individuals without personality pathology can temporarily regress to a state of idealization in the phase of falling in love, which is experienced as infatuation. The key to a healthy love relationship is to then accept and integrate the imperfections of the object of love. Some BPD patients come across as “closet romantics,” seeking love but never finding a version that meets their ideal.

While BPD patients often begin therapy with angry and suspicious feelings in the transference (the experience of the relationship with the therapist), as treatment progresses, positive affects generally begin to emerge, making it possible to work toward integrating the extreme positive and negative poles of the patient’s internal world. However, the experience of positive affects may be as extreme and unrealistic as the experience of the paranoid negative affects and can include sexual feelings. Young therapists who complain about how difficult it is to be the object of anger in the phase of negative transference often report in supervision that it is far more difficult when the patient comes to them with feelings of love.

An erotic transference can involve categorical demands by the patient to obtain gratification of these erotic wishes from the therapist, as in the case of a patient who said: “Let’s both leave our spouses and run off together.” In these circumstances, the therapist’s task is first to work through his or her countertransference sufficiently to be able to discuss the patient’s sexual feelings, wishes, and fears without either undue inhibition or any enactment. The therapist must be able to fully tolerate emotions and fantasies about the patient without communicating them to the patient in order to use them for an in-depth understanding of the patient’s mind.

The therapeutic frame should allow the patient to fully express his/her erotic feelings in relation to the therapist without experiencing that possibility as either a sexual seduction or humiliation. The therapist, in turn, should be prepared to analyze the many aspects of the patient’s fantasies of being rejected because of the therapist’s maintenance of consistent boundaries. Full exploration of sexual fantasies in the transference is an important precondition for the liberation of the patient’s sexual life from the power of paranoid fears that assume rejection.

These moments can be some of the most challenging in therapy. The patient’s expression of interest in the therapist may be direct (“I don’t know how to say this, but I’ve got a crush on you.”), joking and ironic (“I’d love to go out with you, but I know you’d never be seen in public with someone like me.”), or indirect and nonverbal. The therapist’s first task is to not avoid the material. The most rejecting response is to give the message that these feelings are taboo. The therapist should proceed with clarification—can the patient say more about his/her attraction? What are his/her fantasies?

If the patient says he/she cannot proceed, that it is too humiliating, the therapist should inquire about the patient’s assumptions: What makes it humiliating? Why is the patient convinced the therapist does not like him/her? What keeps the patient from imagining that if the patient and therapist met in different circumstances they might not enjoy each other’s company or even strike up a relationship? Open exploration of these issues sheds light on both the patient’s search for the ideal other and on the patient’s devaluing of himself/herself, both of which frustrate the ability to find an appropriate partner in life.

In summary, an erotic transference may be considered both a threat to treatment and an important part of treatment to be worked through. It is often the most challenging aspect of treatment with borderline patients. ■