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Interview: Psychotherapist Neetu Sarin on Boundaries and Sexuality in Psychoanalytic Therapy

Neetu Sarin is a psychoanalytic psychotherapist and faculty member at Ambedkar University, New Delhi. She is interested in issues regarding the body, the unconscious intergenerational transmission of trauma, and is deeply invested in relationships and plants.

Tanisha Chadha, who interviewed Neetu Sarin says, “Psychoanalysis is an approach of psychotherapy that looks at boundaries in a manner that can inform the therapy process beyond just the purpose of maintaining a professional relationship between the therapist and the patient. I wanted to explore how sexuality and boundaries come together or work tangentially in a psychoanalytic clinic through the lens of the therapist, and understand how and why it may or may not be different from patient to patient.”

Tanisha Chadha: What is meant by ‘boundaries’ in a therapy setup, both in terms of the setting involved and therapy as a process?

Neetu Sarin: The initial discussions on how often one would meet for therapy, the time and duration of the session, the discussion of fee, etc. are a way of starting off the therapeutic setting (like rules of the game) and they become boundaries once the patient starts to imagine or explore how much they can/want to bend the rules. The purpose of boundaries needs to be clear and is person-dependent. They are not just arbitrary rules.

Boundaries range from behaviours like not meeting the patient outside of the therapy setting (avoiding a dual relationship), not encouraging gift-giving too much and distinguishing between one’s own needs and that of the patient. Also, boundaries do not have a meaning until you know who you are dealing with. Someone who visits a clinic for psychological help like self-exploration, may have higher psychological resources (there are always exceptions) to deal with boundaries than someone who may have undergone acute crisis (for example, a suicide attempt, domestic violence, a child who has been rescued from an abusive family, etc), in which case the boundaries would be far more flexible. When people are very ill or have undergone acute crisis, there is a high chance of them dealing with distance as being too violent, and so the therapist has to make oneself more available. Therefore, boundaries are dependent on what level of development the patient is at. I would therefore, decide on the basis of the patient’s psychic organisation how I would like to approach boundaries with them.

A therapist constantly keeps two states of subjectivity together. One is the here and now of what the patient is saying in therapy, and the other of what the patient is not saying, not thinking and not doing. In psychodynamic therapy, keeping the possibility of fantasy alive is crucial. So, for instance, if the patient has a fantasy of stalking you on Facebook, you do not tell them upfront not to stalk because that would mean bringing in a prohibition without the desire actually being talked about. But I would address it, if the patient sends me a friend request. A therapist has to think at every step who the boundaries are for. Anything that is too easy, would stall the work. If a difficult patient who is very demanding asks their therapist to come for their child’s birthday party, and the therapist obliges – giving in here seems the easy way out for the therapist to avoid conflict with the patient. But in dynamic therapy, conflict and the inability to deal with it is very much a part of a person’s difficulties. In such a case, a boundary violation is what can help the therapist understand that this is an area where the patient is struggling. The content of the boundary violation, at what moment in therapy a boundary violation comes up and how the client deals with your saying “yes” or “no”, is important information about the patient’s psyche that serves to inform the therapy process.

Tanisha Chadha: You identify as a ‘psychoanalytical/psychodynamic psychotherapist’. Could you briefly describe here what that means and how it is different from other therapeutic approaches?

Neetu Sarin: I think it’s very important to mention here that psychoanalytic psychotherapy is a dying form of therapy, as otherwise boundaries become difficult to talk about. A psychodynamic (a form of therapy that derives from classical psychoanalytic therapy but has evolved in many ways over time) therapist is anybody who believes that the developmental years of a patient are important. So, if a patient brings up issues with their boss, it is about their boss but it is also about the difficulties with authority that they may have faced in their growing up years. A psychodynamic therapist needs to already have their own narcissism in check and know that it is not about them but about the patient. They need to be comfortable with being silent and speaking lesser than the patient, and are also trained to induce what is called transference, which means that in a therapeutic relationship one tends to become a significant other from the past of the patient.

For example, if a patient was to feel exaggeratedly angry at me for being late for the session by two minutes, I would not try and defend myself that it was only two minutes. Instead, I would try and understand which disappointing caregiver did I become for the patient in that moment and then try to re-evoke that image. I also use dream-work a lot. It helps to see the significance of what the patient is thinking when they are not thinking. And of course, the significance of unconscious processes in how one makes decisions.

Tanisha Chadha: On a lighter note, Freud is commonly understood as having been ‘all sexual’ in how he perceived and understood the human psyche. How would you comment on this?

Neetu Sarin: I’m glad that you asked this question. Because, if I were to be asked if psychoanalysis is about Freud, I would say a big “No”! It started with Freud, but analytic and/or dynamic work has come a long way. And more than sexuality, understanding how our attachments (avoidant, ambivalent, clingy, impulsive, etc.) shape us has become an area of focus (called the object-relations approach). This determines our relationships and how we deal with the world around us.

Additionally, I also feel that the reading of Freud is hugely misinterpreted. Freud talked about eros and sensuality, more than ‘sexuality’ per se. I have a problem with equating psychoanalysis with Freud. I feel more influenced by people who have years and years of clinical work experience with children and adolescents like Donald Winnicott and Wilfred Bion, and feminist psychoanalysts like Juliet Mitchell, Nancy Chodorow, Muriel Dimen and Judith Butler. So, saying that your issues with your mother are because you have feelings for her, is incorrect as that is only a part of one’s attachment with their mother.

Tanisha Chadha: Is touching/hugging/going out to a different location for a session to show support to a patient considered all right in a therapy setting? (This was much talked about after the release the 2016 Hindi film Dear Zindagi.) Why or why not?

Neetu Sarin: It is crucial to distinguish between things that are therapeutic and things that are psychotherapy. I think Dear Zindagi is a creative person’s take on what therapy can do and how it can help people. I don’t think sessions like that happen in real life. Touching and hugging need to be put in the context of who the patient is. It is important to look at the mental and psychological level of development of the patient. Touch becomes an important tool in the case of psychotic states where the mind is fragmented and mental faculties collapse. So, for a psychotic patient who is paranoid and feels that all the food being given to them is poisoned and/or that the world is out to get them, physical boundaries need to be loose and flexible, to develop trust. In cases of such psychotic functioning, which is commonly understood in psychoanalysis as the state of the baby (examples would include psychotic disorders where the person loses touch with reality, like in schizophrenia), touch and hug become extremely important. I might use touch to soothe and calm down a very manic patient; but with neurotic and adult-like states wherein the patient is mainly dealing with relational difficulties, touching and hugging need not be a part of the therapy process.

Tanisha Chadha: Are erotic transferences (patient falling in love with the therapist and/or vice-versa) common? What can it mean and how does a therapist approach these boundaries?

Neetu Sarin: Let us first look at why this would happen and what is understood as ‘erotic’. Erotic is that which is sensual and intimate. It is the imagination of being next to a person in one’s psyche and one’s being. Erotic is not the desire to just have sex with someone, but the desire to get close to someone. When a patient falls in love with their therapist, the latter may choose to encourage or discourage it depending on their therapeutic approach. Cognitive behaviour therapy (a form of therapy that focuses on changing negative and dysfunctional patterns of thought) does not work with transference, but psychoanalysis does.

To be a good therapist, it is essential to have an in-depth understanding of one’s own sexuality and sexual desires and to be able to separate them from those of the patient. When a patient falls in love with the therapist, it also about falling in love with being heard and the safe space that the clinic provides where the therapist understands their needs and sees legitimacy in the patient’s conflicts. This process of the patient falling in love with the process of therapy needs to be encouraged while also being careful to not violate boundaries and prevent the erotic from becoming sexual. So, if a therapist feels that the patient is in love with them, they can help the patient make sense of what this may mean for the patient. Does the patient feel the need to be in love with someone who makes them feel heard and accepted? What are the needs that the therapist is fulfilling for the patient that is making them feel this way? This helps the patient to develop a vocabulary for their inner life, and this process becomes therapeutic.

Also, as a therapist one has to be careful not to be seductive. If one’s own needs of acceptance and desire are unfulfilled, therapists may also tend to turn to their patients, which should not happen. The therapist needs to therefore look at whom the encouragement is helping – the patient or their own need for validation, and accordingly take a call on how to tackle the transference.

Tanisha Chadha: Is it always easy to maintain boundaries by being able to distinguish between the therapist’s and the patient’s needs?

Neetu Sarin: It becomes easy for anybody who has done years and years of psychotherapy and work on themselves. It makes them more cognisant and aware of their own needs and feelings. Self-work is a mandate for the training of a psychoanalytic psychotherapist. It is essential for every therapist to undergo self-work to understand the meaning behind their own attachment patterns so that they are able to distinguish them from those of the patient.

Tanisha Chadha: Does psychoanalysis lay out any kind of guidelines regarding what kind of sexuality/sexual act is right/wrong? 

Neetu Sarin: Oh no! Why? (laughs) Anything that is too correct is not sexuality!

Tanisha Chadha: While Freud was also one of the first people to say that sexuality is a continuum and everyone is inherently bisexual, it is also commonly understood that Freud did not see a homosexual orientation as a ‘healthy’ resolution in his theory. So, how are ‘controversial’ desires (like desires for same-sex or BDSM sexual acts) understood by psychoanalysis? Have things changed since Freud in this regard? 

Neetu Sarin: There is a large space within psychoanalysis (Donald Winicott, Jessica Benjamin, Adam Phillips, Joyce McDougall to name a few analysts) where theorists post-Freud have worked in-depth in the area of the body and opened up the space to fetishes, bondage and play-acting. What I would call therapeutic would be to see what a certain sexual act/desire means to my patient.

Be it in a heterosexual relationship or a homosexual one, the concept of one partner being the female and the other being the male (or, butch and femme) is hugely challenged. Psychoanalysis recognises the masculine and the feminine, but it sees them as parts of a person. A woman may have masculine and feminine aspects and so may a man, and people of other genders. This is also interchangeable and reversible. Such ways of thinking easily allow for a non-heteronormative understanding of sexuality within the clinic. I believe that a thorough reading of Freud is hugely needed. When I think of Freud, I think of a homosexual man for whom all of his theories came out of his relationship with men (his father, Wilhelm Fliess, and Sándor Ferenczi). In this way, psychoanalysis came out of a homosexual project.  While working on his theories, Freud realised how attached he was to men and how these relationships had a deep impact on his own attachments and consequently, his theories.

Tanisha Chadha: Following from the previous question, we understand that the clinic is a non-judgmental space wherein queerness, in principle, will be accepted. Has it been a challenge for you personally, to find theories that are progressive and in line with your personal values of being rights-based?

Neetu Sarin: There is huge cultural discord between the texts that we study that are largely European/American, and our Eastern culture. The former view the mind as as Descartian, i.e. either male or female. Whereas, in Eastern cultures, androgyny has always been a part of mythology. For instance, men dancing with dupattas (long scarfs traditionally worn by women in parts of South Asia) at cultural events is something a Western theorist would find disturbing but I would not.

I have had to discard and overwrite a lot of theory because it does not fit with practice. Theory is like a blueprint but it is not a frame that practice has to fit in to. Experience and practice should inform theory as a constantly ongoing process. I do take my work with queer patients for supervision, and we discuss and even write about new and interesting breakthroughs. I think Indian psychoanalysis is in a state of flux because we do not have much published literature that is queer-friendly and relevant to our context, and this is why we constantly struggle with what how the West looks at things and we then try to reimagine it in the Indian context.

Tanisha Chadha: Interestingly, this sounds to me as another form of a boundary negotiation (of trying of reinvent theory with practice) that the therapist takes on with their own discipline, to stand up for their patient. 

Neetu Sarin: That’s an interesting reading of it! I would like to share an example here of a patient of mine who was deeply narcissistic and once brought in prasad (material substance of food for a religious offering) from a puja (prayer service) into the session and offered it to me. For this person, owning up a part of his Hindu ritualistic culture was like coming of the closet.  I did accept that because I felt it was important for him to own up to something he had disavowed for so long. In ‘classical psychoanalytic’ terms, this would be looked at as a boundary violation because of accepting gifts from the patient. I think, however, that this was a boundary extension and not a violation. It would have been a violation had it not been thought through.

Tanisha Chadha: How does psychotherapy/psychoanalysis approach any sharing by a patient which may bring up issues on the part of the patient – like non-consensual sexual acts, being a perpetrator of sexual violence, etc.?

Neetu Sarin: To be a therapist, you have to be okay with being politically incorrect, no matter how much your own ethics and liaisons from institutions demand you to report. Because if a patient tells you that he beats up his wife, it is as much an appeal for help as much as it is a confession. So, in my personal position, I would first try to understand with the patient what happens in that moment that prevents him from being able to control himself. With persons who are perpetrators of violence, we often see that there has been a very early foreclosure of their needs, meaning an early psychological disturbance of emotional needs, as a consequence of which they have had to resort to violence for communication. In such a situation, I have to become what is called a transformative object – that both holds the patient’s violence and helps them undergo change. Reporting doesn’t allow one to hold or contain the madness of the patient, which is actually essential in therapeutic work.

Non-negotiables like being a perpetrator of child sexual abuse, is hypothetical for me as I have never had a patient like this, and answering something based on the hypothetical is difficult for me, as it is devoid of the logic of the unconscious. Trying to imagine it, I think I would definitely spell it out to the patient that it is abuse and violence; because for a lot of people who are very disturbed, it may not even get formulated as abuse in their minds.

Cover image courtesy of Neetu Sareen