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The Role of Sexual Fantasies in Psychotherapy

The noblest pleasure is the joy of understanding.

—Leonardo da Vinci

Not everything that is faced can be changed; but nothing can be changed until it is faced.

—James Baldwin

 

In the course of investigating the twists and turns of a patient’s life, I inevitably encounter sex. In this chapter I want to describe how I work with sexual fantasies in psychotherapy. How does sex emerge as a topic? How do I approach its investigation? If the dynamics of sexual arousal involve someone’s most important psychological conflicts, how do I work with the many bridges between sexual and nonsexual issues? If, as I’ve argued, fantasies negate certain pathogenic beliefs that inhibit us, and if some of our basic problems in life stem from these same beliefs, then how do I use fantasies as a tool in understanding what really ails my patients? To answer these questions, it is important to describe in much more detail than I have so far exactly how I work as a psychotherapist.

The manner in which I practice psychotherapy is well suited to uncovering the hidden meanings of sexual fantasy because it is based on a theory of the mind that is especially sensitive to these meanings. When a patient and I discover the unconscious logic behind a particular sexual preference or daydream, we open a door to understanding the causes of the psychological problems that brought the patient into therapy to begin with. In my practice, these problems usually are not explicitly sexual in nature. In contrast to a sex therapist, who specializes in treating sexual dysfunction, I treat people seeking help with more general life problems, from marital strife, to work inhibitions, to severe states of depression and anxiety. As a result, my approach to sexual fantasies and sexual preferences, when they do emerge in therapy, is not to change or “fix” them unless this is something the patient explicitly wants. My clinical strategy involves making use of patients’ sexual fantasies and preferences to illuminate the innermost workings of their minds, which as a result helps us solve their other, nonsexual, problems.

Most of us are unaware of the deeper meanings of our sexual fantasies or preferences and lack the motivation to discover them. We go through our lives having sexual thoughts and daydreams every day, getting aroused now and then, and never feel the need to understand the exact chain of mental events that precede and cause our experience. Except if we’re in therapy. In therapy people not only have the opportunity, but often the motivation, to explore their sexual wishes and fears. The opportunity arises because the therapy relationship creates conditions that are safe enough for people to talk about private and embarrassing subjects like sex. The motivation comes from a number of sources, depending on the patient. Some people obviously want to talk about their sexual thoughts and feelings when sex is a problem of some kind. My patient Rob, for example, consulted me because of his inability to get, and stay, sexually excited with his wife, Nicole. Our psychotherapeutic work began with an exploration of Rob’s feelings about sex and focused on the conditions under which he could get aroused—including in his fantasies—and those under which he would become sexually inhibited.

Sometimes patients enter therapy with sex the furthest thing from their minds, only to find it surfacing as the therapy proceeds. Jim and Laurie, for example, didn’t come to see me because of sexual difficulties but because of their concern that stresses in their relationship were contributing to their son’s psychological difficulties. It emerged during our consultation that one of their stresses was, in fact, a significant sexual problem involving Laurie’s need for a special kind of stimulation and Jim’s discomfort in providing it. Esther, of the Mardi Gras fantasy, sought treatment for depression not sexual difficulties. It was only in the course of exploring her low self-esteem that the importance of her sexual inhibitions and exhibitionistic fantasies emerged.

In my experience, the more common clinical situations in which the causes of sexual excitement are discussed are ones in which the focus isn’t on sex at all. Instead, in the course of dealing with such problems as low self-esteem, anxiety, marital discord, or work inhibitions, patients discover that their sexual fantasies shine an especially bright light on the nonsexual problem with which they’re struggling. This was the case with my patient Matt, who came to see me because he was having panic attacks in response to competition and conflict at work. In the course of exploring his fears of confrontation and his guilt about self-assertion, Matt eventually revealed the details of his addictive use of phone sex. Neither he nor I viewed phone sex as his central problem, but we were able to use it to get to the heart of the issue that lay behind Matt’s difficulties at work, namely his irrational guilt about burdening and draining others with his needs. The presence of guilt was not surprising to either of us. Rather, Matt’s phone-sex fantasy threw into sharper relief the origins and meaning of this guilt. Based on this understanding of Matt’s sexual fantasy, we better understood the difficulty he had at work in aggressively asserting his own interests. Matt unconsciously believed that if he demanded what he needed at work, his coworkers and bosses would feel burdened and drained just as his mother had.

Thus, some people seek therapy for help with sex, and others use sex to help with their therapy. However, despite their potential therapeutic utility, sexual details are difficult for many people to talk about. Often patients only hint at their fantasies; and when they do reveal them, they’re couched in generalities. This reticence isn’t necessarily problematic. Sex isn’t all there is to life and, therefore, to the process of changing one’s life. While sexuality is an important channel to and from the core of our psyches, it is not the only one. I have had people in therapy for many years, plumbed the depths of their feelings about themselves, their families, and their partners, and helped them resolve core issues in their lives, and never elicited any significant interest on their part in discussing the gritty details of their sexual fantasies or behavior. On the other hand, my clinical experience also tells me that while sometimes the absence of such discussion is due to a lack of clinical relevance, more often it is a function of shame.

SHAME, SELF-ACCEPTANCE, AND SEXUAL FANTASIES IN PSYCHOTHERAPY

Sex is embarrassing to talk about even in the context of a confidential, nonjudgmental therapy relationship. As a result, patients will frequently censor their sexual thoughts and feelings. They will talk about the most private aspects of their work and love lives, recount the most embarrassing situations of their childhood, and reveal their most unflattering thoughts but resist talking about the details of what sexually arouses them or turns them off. At one level this resistance merely reflects the general shame and repression that surround the subject of sex in our culture. Despite the fact that we’re all bombarded with sexual images by television, movies, magazines, and billboards, and despite decades of sex education and self-help books promoting sexual honesty and communication, most of us still feel that the details of our sex lives are private and not for public consumption, even by a therapist. There is still a widespread view of the body as shameful and its products and appetites as forbidden.

The sexual shame I see in my patients, however, is not just a function of a repressive culture. Sometimes it involves specific and personal concerns that their thoughts and preferences are pathological, shamefully deviating from their personal ideals and self-image. My patient Jan, for example, was a feminist who was ashamed about her rape fantasies. However, after she understood the true meaning of her fantasy—that it was intended to overcome her guilt about being stronger, not weaker, than men—she felt much less ashamed and more self-accepting. One of the goals and benefits of psychotherapy involves lessening patients’ shame about their sexual fantasies and desires by understanding their underlying motivations. Patients often feel embarrassed about their sexual thoughts because they assume that their thoughts define who they really are. But Jan didn’t really want to surrender her power in real life to a man or be actually raped. Psychotherapy can help people distinguish between who they fantasize themselves to be and who they really are. Insight always enhances self-acceptance.

In the real world, however, fantasies are not always completely private. Sue, a woman in therapy with a colleague of mine, preferred real sexual practices that were rough and based on heterosexual sadomasochistic roles, involving behaviors ranging from light bondage or enactments of rape to actual physical pain and humiliation. Sue also believed, with some embarrassment, that her sexual behavior expressed her innermost longing for a man to overpower her. She couldn’t let herself off the hook by reminders that her fantasies didn’t reflect what she really wanted; her actions apparently spoke louder than mere fantasies. The question, then, arises: since Sue is acting out, and not just fantasizing about, her desires, doesn’t the difference between fantasy and reality become blurred? In my clinical experience, Jan and Sue are more similar than different, and the clinical distinction between fantasy and reality is still crucial. The manifest behavior that Sue prefers in the bedroom is no more a transparent expression of her “true” self than is Jan’s private daydream. Neither Jan nor Sue wants to be weak or raped in reality; both insist that the actual sex that is occurring is consensual, and both ultimately are getting excited by the fantasy of being helplessly overpowered while remaining, in reality, in control. Jan’s control is obvious since she is the sole author of her fantasy, while Sue’s control is hidden but just as real. Sadomasochistic scenarios, like the ones that Sue enjoys enacting, always give the masochist the power to say no at every moment, to regulate the exact amount of helplessness, humiliation, or pain that she or he endures. Sue is in charge of her own domination.

Neither woman is actually overpowered. Sue, the practicing masochist, is engaged in the same fantasy as Jan, the imaginary masochist, and for the same reasons. It is irrelevant, in terms of the psychological meaning and function of the fantasy, whether the theater in which it is staged is public or private. Sue may be obliged to modify her fantasy in order to accommodate her partner, while Jan is not, but the underlying issues are the same. Both women are attempting to overcome feelings of guilt and pathogenic beliefs about hurting their partners by arranging to be dominated and “forced” to have sex. Domination is the imaginary means to a pleasurable end, not the end in itself.

Whether we act out our fantasy in a consensual way or keep it as a private daydream, we are writing a script, performing a role, and the result is theater, not reality. When patients like Jan and Sue come to realize this in therapy, they feel less shame and, as a result, improve their self-esteem.

The clinical importance of the distinction between fantasy and reality was equally important—and complicated—in the case of Otto, the patient who admitted that he masturbated to pornographic images of teenage girls. The main issue in Otto’s therapy wasn’t sex at all, but his struggle to feel more separate from his wife and to decrease his reactivity to her perceived imperfections, which, to Otto, included both her tendencies toward depression and the physical signs of her aging. In the course of trying to treat the problems in his marriage, his use of pornography surfaced, and our analysis of its true meaning helped his overall treatment enormously. Otto’s primary impulse was not to go out into the real world and have sex with teenage girls but instead to achieve sexual pleasure through a fantasy scenario that felt safe. Once he understood that teenage girls unconsciously represented happy women for whom he didn’t have to feel responsible and by whose moods he wouldn’t have to be contaminated, and not real girls whom he wanted to use and exploit, Otto felt more sympathy for himself and less shame. As a result, he and I were able to work productively on the psychological problems of guilt and identification that were creating the need for pornography to begin with. Such use began to decrease, and his relationship with his wife improved.

The cases of Jan, Sue, and Otto illustrate how psychotherapy, by explaining the hidden logic behind sexual fantasies, can reduce patients’ shame and even open up the possibility of changing the basis of their sexual arousal. I say “open up the possibility” because understanding our fantasies doesn’t necessarily mean that we want, or need, to change them. Instead, we may simply use increased insight into their meaning to feel better about having them to begin with. Many of us feel weird or deviant about the ways that we get aroused, and understanding the secret logic behind our preferences can feel liberating in and of itself without producing any other change whatsoever.

If we do want to change them, however, deciphering their hidden meaning will help us in several ways. Only when we see that our sexuality is a product of the human mind, that it is constructed and not somehow embedded in our chromosomes, can we conceive of changing it. In addition, if we want to alter our sexual fantasies, we have to first eliminate the shame surrounding them. Therefore, reducing shame by analyzing the unconscious origins of our sexual fantasy life is a necessary, although not sufficient, condition for change.

Whether or not we want to transform our sexual natures, it is important to remember that the presence of a fantasy isn’t necessarily a psychological problem in and of itself but a way that the human mind manages to create what it perceives as safe conditions under which it can achieve sexual pleasure. There are exceptions to this rule. Sometimes patients explicitly work in therapy to change a fantasy or preference because it is interfering with their lives—disturbing their relationships or putting them at risk in some way. A patient whose treatment I supervised wanted his wife to dress him up in women’s clothing as a prelude to sex, a request that horrified and disgusted her and led her to shut down both sexually and emotionally. This patient loved his wife and wanted to restore their intimacy, and so he sought to figure out ways that he could incorporate elements of his fantasy into their lovemaking in ways acceptable to her. The only way he could do this successfully, however, was to understand the inner dynamics of his cross-dressing preference.

We came to understand that his wish for his wife to dress him in women’s clothing involved his guilt about secret feelings of superiority to his wife and women in general. Cross-dressing, it turned out, was a way of abasing himself in his wife’s eyes in order to magically reassure her that he didn’t look down on her or other women. After analyzing these dynamics, he found ways to enjoy forms of sexual submission in which his wife was able to happily participate.

Other times, of course, therapy needs to focus on changing a sexual fantasy regardless of the patient’s expressed wish to do so. If Jan were to act out her rape fantasies by picking up strangers, she might well be exposing herself to disease or physical assault; and whether or not she wanted to change her fantasies, I would view them as problems that needed treatment. And whether or not he saw it as a problem, if Otto were to act out his fantasies by attempting to seduce teenage girls, I would view this not only as harmful to the girls but to himself and make the process of analyzing and changing his fantasies an urgent priority. The point here is that therapists should never take their patients’ view of their own sexual fantasies at face value, just as therapists would never sit back and passively accept their patients’ manifest willingness to solve other problems as the ultimate guide to therapeutic technique. To use an extreme example, if a patient told me that he was thinking about killing himself by jumping off the Golden Gate Bridge and that he didn’t view this as a problem in need of treatment, I would disagree and actively attempt to change his thinking and stop him. (In fact, the therapist is not only ethically obliged to prevent suicide, stop child abuse, and warn potential victims of a patient’s intent to harm them, but in most states he or she is legally obliged to do so.)

My general therapeutic stance toward a patient’s sexual fantasy life, then, straddles the fence between following the patient’s lead and following my own. Unless a patient gives me reason to believe otherwise, I don’t automatically think that his or her daydreams or preferences are clinical “problems” to be solved. On the other hand, I am cognizant of the fact that patients don’t always know what’s best for them and may need the benefit of my protection and authority in order to avoid harming themselves. Having said this, the fact remains that most of the time my approach to eliciting and understanding my patients’ erotic imaginations is entirely guided by them. My role is to attempt to understand patients’ fantasies from their point of view, to listen carefully for what these fantasies mean to them. Except when my patients’ fantasies or preferences threaten to hurt themselves or others, I attempt to leave my own values, politics, and sexual predilections at the consulting room door.

THE ROLE OF PATHOGENIC BELIEFS IN PSYCHOTHERAPY

I approach the subject of sex in exactly the same way I approach every other topic in therapy, namely by attempting to decipher its deepest level of psychological meaning from the patient’s subjective point of view. Like most therapists, I try to use empathy to see the world as my patient does. I understand the essence of psychological meaning, however, in a slightly different way than many other therapists. Influenced by the groundbreaking psychoanalytic research of Joseph Weiss and Harold Sampson, I believe that people in therapy are always struggling against their pathogenic beliefs, unconsciously looking for ways to disprove and transcend them. Some therapists, particularly some psychoanalysts, view their patients as caught between their wish to grow and their wish to remain sick. The clinical approach of these therapists emphasizes the importance of dealing with their patients’ “resistance” to change, that is, their attempts to thwart and sabotage the therapists’ efforts to help them in the service of holding on to their symptoms. In contrast, my approach is based on the belief that people not only come into therapy with a wish to change and master their pathogenic beliefs but even have an unconscious strategy about how to do so.

Of course, most people don’t come into therapy complaining about their pathogenic beliefs. They don’t usually say such things as, “I feel like I don’t deserve the good things in life,” or, “I have a fundamental sense that the world is scary because that’s the way my family felt.” They come into therapy with such problems as insomnia, marital conflict, depression, or fears of flying. Their pathogenic beliefs lie just below the psychic surface, organizing their experience of the world, and yet the patients themselves are not usually conscious of these dynamics. In my experience, while patients can’t usually tell me about their pathogenic beliefs, they subliminally know they are there. They can feel them at work. One of my main goals as a psychotherapist is to help patients discover, describe, and thoroughly understand their pathogenic beliefs.

Joe, a patient of mine, complained bitterly about the fact that his wife was selfish and that he felt he was constantly giving her more than he was getting. He felt the problem lay primarily in his choice of a partner not in his pathogenic beliefs. As we talked about his family background, however, Joe revealed, in moving terms, similar feelings of sacrifice and self-abnegation that he’d felt as a child. His father had been disabled by a stroke when Joe was seven years old, and his mother had had to work to support Joe and his three younger sisters. He was given the responsibility of caring for his sisters much of the time and felt that he was forced to give up his own childhood in order to fill in the gaps left by his parents’ physical and emotional absence. Joe developed a series of pathogenic beliefs as a result. He wasn’t supposed to want anything for himself, he wasn’t supposed to complain, and he should always take care of people less fortunate than himself. He grew up feeling guilty about wishes to put himself first or to be taken care of.

Joe married a woman who was somewhat needy and with whom he felt drawn to replicate the painful childhood situation in which he was forced to be a caretaker, a pattern that confirmed his pathogenic beliefs about relationships. Given these beliefs, Joe could never ask his wife for anything and had difficulty refusing her requests. After he and I came to see how understandable, albeit painful, it was that he had grown up feeling that he was supposed to give up his own life for others, and how he was reenacting this situation with his wife, Joe began to experiment with saying no to her and with articulating his own needs more clearly. To his delight and surprise, his wife was more resilient than he had thought and became more responsive to his need for caretaking.

Joe’s case illustrates a common pattern: people often begin therapy with a false or incomplete theory about what ails them, but respond quickly and positively when their underlying pathogenic beliefs—the real source of their problems—are identified.

Consider the case of George, a thirty-six-year-old physician who consulted me for help with his depression two months after he had separated from his wife of ten years. He and his wife shared custody of their six-year-old son. George was miserable about the damage that his decision to separate might do to the boy. In the first session he told me that even though his wife had herself also been trained as a physician, she had cut back on her medical practice in order to raise their son, leaving George as the primary breadwinner in the family. George described his wife as chronically depressed and passive, highly critical of him, and almost completely uninterested in sex. In his experience, his wife, while a devoted mother and housekeeper, expected George to completely take care of her (she was relieved, he believed, when the birth of their son gave her a good reason to stop working) but rarely did the same for him.

George told me that he thought he was depressed because he was grieving the loss of his marriage and family. He had recently read a book about divorce that explained how people in his position need to go through the same stages of mourning as someone does in response to the death of a loved one. George got choked up when he told me that he felt alone and sad much of the time and needed help experiencing and working through his grief.

I asked George to tell me a bit about his childhood. He told me that his father was a salesman who was rarely home and that his mother was a “survivor.”

“Do you mean from the war?” I asked.

“No, from her life,” he said. “She always seemed like she was barely surviving being alive, much less being a mother. Everything was hard for her. When I think of my childhood, I think of my mother’s strained, unhappy face.”

George told me that he learned early on that life really began when he left the house and that it had to be put on hold when he returned. He kept his outside life secret from his mother, he said, because if he showed too much excitement or enthusiasm at home, he sensed that his mother became more depressed and bitter and would find a way to deflate him. George described himself as a bit of a loner, the kind of child who always daydreamed. His primary daydream as a child, he told me, was that he was part of someone else’s family. When George met his wife in medical school, he found her attractive and serious. “I didn’t hear any bells ring or fireworks explode,” he said, “but she felt comfortable to be around and seemed like she could provide a secure home.”

As I listened to George, I wondered about his pathogenic beliefs. He presented his grief and loss as his main problem, and yet his wife, like his mother, seemed more like someone you’d feel relieved to get away from rather than sad about losing. Sure, I told myself, one can feel a lot of pain losing someone who is familiar, even if problematic, and George’s partial loss of his son had to be emotionally significant. Still, the fact that he evinced no relief but only sadness about the separation did not make complete sense, even though he was sitting in front of me crying. My experience, as well as my theory, told me that pathogenic beliefs involving separation and survivor guilt were often operative in troubled marriages like George’s, keeping them together too long and making their dissolution especially painful. Given the parallels between his wife and his mother, I wondered if George’s real problem might lie as much in his guilt as in his grief.

To test out this speculation, I said to George, “You mentioned that you kept your accomplishments secret from your mother. I wonder if one thing you might be keeping secret from yourself here might be that you actually feel relieved about leaving your wife and feel guilty about it, like you’re not supposed to want to have an easier life with someone you can have fun with and who can take care of you for a change.”

There was a pause, and suddenly George stopped crying and began to laugh. “I’m not sure why I’m laughing,” he said, “but somehow what you’re saying feels completely right, like a weight is being lifted. Somehow I must feel that this separation process is supposed to be really hard, just like everything else in my life.”

I suggested that since George felt guilty about leaving and about being glad to get out, he had to make the entire process as painful as possible, filled with grief, loneliness, and torment, rather than acknowledge his hopefulness and joy. George went on to talk about how terrible life had been with his wife, especially over the last few years, and how excited he secretly felt about the possibility of a new life.

George’s conscious view of his depression was that it was caused by feelings of loss. The real cause of his depression, however, was his separation guilt, his pathogenic belief that he wasn’t supposed to leave an unhappy woman behind in order to “selfishly” pursue his own pleasure. Because of his guilt, George’s sadness and feelings of grief were exaggerated in order to conceal from himself his relief and excitement. His case illustrates how patients come into therapy suffering from pathogenic beliefs of which they are unaware but which, when correctly identified and understood, can produce immediate relief and stimulate psychological growth.

One of my main goals, then, is to help my patients become aware of their pathogenic beliefs and change them. This is often a slow and difficult process because these beliefs are not factual ones, such as “the earth is flat,” which could be disproved, or opinions like “schools shouldn’t teach sex education,” which could be altered by a persuasive argument, but instead are often more like sensibilities that feel entirely natural, not even like a belief at all. Pathogenic beliefs are often like breathing—they are taken for granted in much the same way that we take for granted the existence of oxygen when we breathe.

Therefore, my approach to psychotherapy usually involves making my patients aware, metaphorically, of their breathing, conscious that they have these beliefs to begin with, that beliefs are not facts of nature, and that, therefore, they can be altered. Once I am able to do this, my goal is to help patients see that while their conceptions were once a reasonable and adaptive response to their childhood environment, they are no longer either reasonable or adaptive in their adult lives.

I look for evidence of these emotional belief structures in everything that my patients say, feel, and do. One patient I treated tended to feel chronically misunderstood and rejected by other people. He presented plenty of evidence that this was realistically true. He didn’t, in other words, think that he was suffering from a “belief” at all, much less a pathogenic one. At one point he broke his leg and couldn’t leave his house to shop or do even the simplest errands. We were speaking by phone, and I asked him why he hadn’t asked any of his friends for help. He told me that his friends were selfish and that he therefore hadn’t asked. I knew from his history that his parents had often acted severely rejecting toward him, and so I suggested that he believed that his friends would resent his dependence, just as his parents had, and that despite his complaints he secretly complied with the view that he was a burden. I told him that he was seeing himself and his friends through the eyes of his cruel and insensitive parents. Because he was desperate, he agreed that he had to at least try to get some help. He called a few of his friends and asked them to bring him some groceries, which to his surprise, they gladly did. At this point he was willing to entertain the possibility that his chronic feeling of neglect was as much belief as it was reality and, to the extent it was the latter, it might be a self-fulfilling prophecy.

I approach sexual fantasies in exactly the same way—that is, I seek to explore the underlying beliefs that give rise to them, beliefs about which the patient is almost always unaware. Carl came to see me because he was depressed and had a tendency to ruminate so much about every important decision in his life that he was effectively immobilized. He couldn’t decide if he should move, buy a new car, change jobs, put an ad in the personals section, or even if he should jog in the morning before breakfast to get the day off to a good start or wait until the evening in order to unwind and get a good night’s sleep. His descriptions of his childhood were relatively sparse and emotionally flat, even his account of his father’s death when he was young. He did relate one powerful memory about his mother that he sensed was significant. He remembered that she would spend about one hour each morning getting dressed, a process that always included her putting on a wig, even though as far as he could remember there was nothing particularly wrong with his mother’s natural hair. Nevertheless, as he watched her put on her wig every morning, Carl felt that his mother was donning a disguise, something artificial, and didn’t want to hug her because he hated the feel of her synthetic hair. To this day, Carl told me, he can’t stand to be close to his mother and feels that there is something inaccessible and cold about her.

In the course of talking about his desires and frustrations in intimate relationships, Carl told me that he was especially attracted to tall and athletic women. He denied that his sexual preference had any particularly deep psychological meaning, claiming that since he himself was athletic, he simply appreciated a woman who kept herself in shape. A few sessions later, however, he told me that one of his earliest sexual fantasies—the one, in fact, that he first used to masturbate to when he was an adolescent—was a daydream in which he and a girl were boxing and in which he frequently ended up wrestling with her in “clinches.” Something in the hard, physical contact aroused him.

As Carl was telling me about his sexual preferences and masturbation fantasy, I was wondering about his pathogenic beliefs. What sorts of feelings about himself and others would the fantasy of boxing and wrestling with a strong woman address? What ideas might it correct or fears might it assuage? How would it, in the terms of my theory, make him feel “safe”? Based on his relationship with his mother, Carl had grown up feeling that intimacy with a woman was difficult, if not dangerous, that women weren’t very genuine and comfortable with who they were. Given the interpersonal minefield that Carl associated with relationships with women, I surmised that sexual excitement would have a difficult time safely flourishing.

It then seemed clearer how his fantasy and preference momentarily solved this problem and made sexual pleasure possible. First of all, Carl’s ideal woman was big and strong and didn’t need the kind of cosmetic crutches and tresses that his insecure mother seemed to require. Carl’s fantasy woman could take care of herself and didn’t require his, or anyone’s, help or worry. Second, and more important, boxing and wrestling are intensely physical forms of sustained contact. Two bodies collide forcefully. This fantasy negated Carl’s sense that connecting with a woman was difficult and artificial—the connection between him and his female opponent was direct, immediate, and unmistakably real.

I pointed out to Carl the centrality of his feelings of disconnectedness as a child and how, in his sexual daydreams, he unmistakably connected with a woman and did not have to feel that she was faking it. “I guess I can at least be sure that her wig won’t fall off,” Carl agreed.

We were then able to use this insight to understand better his problem of having difficulty making decisions. He told me that when he was faced with having to make a decision, he suddenly felt weak and alone and, as a result, inordinately worried about his ability to make the “right” decision. He wondered if this feeling of being alone had to do with his sense that he couldn’t really lean on his mother or trust that she was really there in his corner. He must have given up expecting help from his mother, he reflected. “If I ever turned around to see if she was really in my corner, I’d probably find that she was fussing with her hair,” he said. Inevitably the conflicts interfering with our sexual vitality are the same conflicts causing trouble elsewhere in our lives.

SAFETY, TESTING, AND CHANGE IN PSYCHOTHERAPY

Because our childhood attitudes and expectations can cause us so much suffering, we come into therapy highly motivated, consciously or unconsciously, to change them but are also afraid to do so; they have, in our minds, protected us against various dangers. If I became placating and deferential as a child because of the belief that my self-assertion would hurt my father and provoke his retaliation, then I might be loathe to give up such a belief as an adult because of the risk, however miscalculated, of reexperiencing the very danger that I’d worked so hard to avoid as a child. The reason people seem to “resist” change is not, as many therapists believe, because they’re deriving gratification from being sick, but because they’re trying to ensure their own psychological safety. At the same time, however, if they come to therapy for help with the distress that their pathogenic beliefs are causing them, they are going to be looking for ways to make it safe to change. As Weiss and Sampson have shown, patients not only look for safety in their therapy in order to change, but they actively attempt to create it.

Patients actively use therapy to establish the conditions that will make it safe enough for them to confront their painful and irrational beliefs and feelings. On the simplest level, they seek to be understood, and when they succeed, as Carl did, they begin to feel safe.

How does understanding help us feel safe? The answer lies in the process by which raw experience becomes personal experience, how our feelings acquire a unique and personal meaning to us. As children we come to know we are angry, sad, scared, or hurt through the responses of our caretakers. We learn to correctly identify our feelings because our parents have correctly identified them first. The old question “Does a tree make a sound when it falls if there is no one around to hear it?” is especially applicable to the concept of psychological pain. Can people know the extent and meaning of their suffering if there is no one around to hear and empathize with it? The answer, generally, is no. If there is no witness to our experience, it doesn’t feel legitimate. Most of us didn’t understand the true causes of our suffering as children and couldn’t articulate our pathogenic beliefs, not simply because our cognitive capacities to do so were limited, but because our environments were deaf to certain aspects of our experience.

Carl’s aversion to his mother’s artificiality, for example, was certainly never understood by his mother, and his father wasn’t around to empathize with it either. Most of us grow up in situations in which our suffering lacks a witness, someone who really “gets” what we’re going through. As a result, we feel tremendously relieved when our therapists finally see, accept, and understand our inner worlds. When we feel seen, we can better see ourselves. We finally have a nonjudgmental witness to help us validate our experience.

Patients acquire a sense of safety in therapy in other ways as well. Weiss and Sampson’s research, and my own experience, have shown that patients actively, if unconsciously, test the therapist to see if it is safe enough for them to bring forth the most troubling parts of themselves for examination and to try out new and healthier attitudes and behaviors. If the therapist passes the test, the patient feels safer and is able to move forward. If the therapist fails the test, the patient’s progress stalls or even regresses. This testing process isn’t random or accidental but is part of the patient’s overall plan for healing, recovery, and growth. As I sit and listen to patients, I am thinking about whether, and to what degree, they are testing me. And when I can figure out the nature of the test, I try my best to pass it and facilitate their plan for mastery and growth.

Patients test in many different ways that, unless one understands this concept, appear paradoxical and confusing. Patients commonly test by inviting their therapist to confirm their worst fears and expectations, to traumatize them in exactly the same way that their parents did originally. They carefully observe and unconsciously evaluate their therapists’ responses as either confirming or disconfirming their pathogenic beliefs, subliminally hoping all the while that the therapist will do the latter.

A patient of mine, Margaret, grew up feeling that her independence threatened her mother, that the mother needed her daughter to remain dependent on her. Margaret’s pathogenic belief that she shouldn’t be independent lest others feel hurt and rejected interfered with her ability to finish college and support herself. When she came to see me, she began subtly to disagree with my interpretations and to make choices that defied my recommendations. I sensed that she was testing me to see if, like her mother, I would become hurt by her independence. If I defensively attempted to assert my authority and control over her behavior, I would fail Margaret’s test, and she would not be able to feel safe enough to face her conflicts about her independence. With this in mind, I took a very accepting and nonchalant attitude toward her contentiousness and tried to remain nondefensive when she disagreed with me, while also attempting to make her aware of what was going on. Eventually, she brought forth a memory that she had previously suppressed: whenever Margaret went to a slumber party as a child, her mother would get a migraine headache. Margaret realized that she had inferred as a child that she was hurting her mother by leaving her. I took this memory to be a confirmation that my understanding of Margaret was correct, and that I had passed her test. As a result, Margaret was able to move forward with the process of understanding her conflicts about independence and changing them.

Patients test in many other ways as well. One patient told me after five sessions that she felt better and wanted to stop. I told her that I didn’t think she was ready, that her problems were significant, and that we should continue our work. The patient seemed immediately relieved and told me about incidents in her childhood where she had been in trouble and no one in her family had noticed or seemed particularly concerned. She described how she used to use marijuana or cocaine almost every day during her last two years of high school, and her parents seemed too preoccupied to notice. My understanding of this situation was that she wasn’t protected as a child and worried that she didn’t deserve protection. By telling me she wanted to stop, she tested to see if I, too, would ignore her difficulties. When I refused and told her that she needed further help, she felt safer and was able to tell me with greater ease about her sense of childhood invisibility and neglect. She couldn’t face this painful aspect of her childhood until she felt assured that it wouldn’t be repeated with me.

Sexual fantasies can often be involved in testing. Matt, the patient with the phone-sex fantasy, related the precise details of his telephone scenarios only after he felt safe enough to do so. This sense of safety was facilitated by the fact that I successfully passed certain of his tests. At first Matt only mentioned in passing that he had an “interest” in pornography, then that he had occasionally tried phone sex, and eventually that he was heavily involved in playing out a very specific sexual fantasy about breast-feeding almost every day. At each stage I attempted to help reduce Matt’s shame about talking about these issues, communicating acceptance and curiosity about what he was describing. I conveyed to him that his sexual interests reflected a perfectly understandable attempt to express certain forbidden longings and to overcome particular inhibitions that he had acquired in childhood. In other words, each step that Matt took in revealing his sexual predilections was a kind of test, inviting me to condemn or pathologize him in some way. When I instead normalized his sexual interests, he felt safe enough to convey their full plot and importance.

Often, patients aim to master their pathogenic beliefs by testing their therapists in quite a different way, a way upon which my own theory and clinical approach place particular importance. I refer to this as “passive-into-active” testing, a concept first described by Weiss and empirically defined and tested by Weiss and Sampson. In passive-into-active testing, patients will often do to the therapist what was done to them, replay a childhood situation in therapy, but reverse the roles and treat the therapist in the same unpleasant ways in which they had felt treated by their parents. The test involves seeing if the therapist will be as daunted and traumatized by this behavior as were the patients themselves as children. They secretly hope that the therapist will be healthier and stronger than they were, and that as a result they will be able to identify with this health and strength, silence the voices of the past, and move forward in their lives.

A patient who was sexually seduced or otherwise abused by a parent might be extremely seductive in therapy, inviting the therapist into all sorts of compromising situations. In this model the patient is turning passive into active, actively repeating her (given the high incidence of sexual abuse among girls, it is usually a woman) experience of seduction, intrusion, and guilt with her therapist, but this time, reversing the roles. The therapist usually passes this type of test by gently refusing the seductive invitations. A patient who had suffered growing up with a parent who was inconsolably unhappy, and who often made the patient feel guilty, might come into therapy and act as if nothing the therapist does is right or can satisfy the patient. The therapist is made to feel guilty about not doing enough for the patient in the same way that the patient felt guilty about not doing enough for the parent. The tables get turned, and the patient carefully—though not always consciously—studies the therapist’s reactions in order to discover a better way of relating. If, however, the therapist gets overwhelmed by feelings of helplessness and failure, and reacts defensively, the patient will not be able to move forward.

I saw an extreme example of this type of testing in a patient, Rita, whom I treated when I was just beginning in private practice. Rita was chronically suicidal but refused to go into the hospital. Nothing I said or did seemed to help her. As time went on, I felt increasingly guilty, helpless, and incompetent. Eventually I realized that she was turning passive into active. Rita’s mother had been chronically depressed and had killed herself when the patient was fourteen. The father had blamed Rita, telling Rita that her mother had been overwhelmed by the burden of raising her. Rita was traumatized by her guilt over her mother’s death, and as a result she had never been able to be happy for very long. She was plagued with the pathogenic belief that she had killed her mother and didn’t deserve to have a life, let alone a better one. Rita’s suicidal tendencies represented an identification with her mother, and in therapy she tortured me—without conscious intent or malice—with the unspoken accusation that I couldn’t help her and, as a result, would be responsible for her death.

Passive-into-active tests are not always easy to pass. In the case of Rita I had to try to demonstrate that I would not let myself feel tormented by feelings of guilt and helpless responsibility in response to her depression and threats of suicide in the same way that she had been in response to her mother’s. In addition to trying to help Rita understand and modify her sense of omnipotent responsibility for her mother and the resulting need to punish herself, I tried to convey to Rita that while I cared a lot about what happened to her and would try to prevent her from doing harm to herself if I could, I wasn’t ultimately responsible for her living or dying and would not be blackmailed into feeling otherwise. Rita was not only outraged by what she decried as my “meanness” but tested it out by making a suicide gesture on the eve of one of my vacations. She called me at home to tell me that she had just cut herself but would not tell me how much she was bleeding, how deep the cut was, and refused to go to the hospital. She was turning passive into active, putting me into a position of helpless and guilty responsibility. I told her that I was calling the police and was having her involuntarily hospitalized until I returned from vacation. She became enraged, telling me that I was abandoning her when she was in her greatest need. I told her that she was trying to make me feel the same way she had felt when she was a child, as if I had life-and-death responsibility for her, and that my wish to go on vacation—symbolically, to enjoy life—was equivalent to wishing her ill. I told her that while she had been plagued with these ideas as a child, they were as false then as they were now, and that I wasn’t going to be victimized by them as she had been. In other words, I was indirectly telling Rita that I was going to protect her and make sure that she was in a place where I didn’t have to worry about her while I was on vacation.

The police did indeed pick up Rita, and she was hospitalized while I was away. When I returned, she was much calmer, and she told me that she was secretly relieved when she realized that I was going to protect myself and that she couldn’t ruin my life with her various machinations. She was able to reflect on how automatically she feels responsible for every bad thing that happens around her and has always felt this way. The therapy began to take on a new flavor, with much less drama and suicidal preoccupation. My passing her passive-into-active test—by not responding to her suicide gesture as if I were a fourteen-year-old girl who felt that she had killed her mother—enabled Rita to feel safer and less guilty herself.

MECHANISMS OF CHANGE IN PSYCHOTHERAPY

Patients come into therapy wanting to master their problems. The goal of therapy is to help them identify and change the pathogenic beliefs that underlie these problems. Deepening their understanding is one important route to change because once we see how our currently painful and unreasonable view of the adult world originated as a reasonable and adaptive response to our childhood world, we not only reduce our shame and increase our self-compassion, we give ourselves the chance to revise this view in a healthier direction. Understanding alone, however, is not always enough to facilitate change.

In order to effect lasting change, people need new experiences in which their pathogenic beliefs are repeatedly proved to be false in a way that they can believe on a deeper level. This is why I often encourage my patients to experiment with new ways of being and acting in order to help provide them with more immediate, visceral, and experiential evidence that the dangers that they anticipate will not necessarily occur. Someone who is afraid of being rejected for being selfish needs to have safe opportunities in which selfishness does not provoke rejection. Someone who worries that he or she will make other people feel drained and resentful by their dependence needs to test out the waters and express their dependency needs.

Often, as in the examples I gave of testing, patients get experiential evidence from their therapist that their pathogenic beliefs are wrong. Therapists are in a unique position to provide such evidence because, when they interact with patients, they are not as distracted by their own conflicts and vulnerabilities as are other important people in patients’ lives. When a patient tests to see if I’ll be rejecting, hurt, devalued, envious, or bored, and I manage to convey that I don’t feel any of these things, then that patient has experienced a small dose of an alternative and healthier reality, perhaps enough of one, if repeated over time, to begin to wear away the foundations of his or her irrational expectations and default assumptions about the nature of reality. Understanding is one-half of the equation, and new experience is the other.

When working with patients’ sexual fantasies and preferences, I don’t use any special techniques but instead approach their sexuality as I would any other important aspect of their lives. However, the question still arises: what do the concepts of pathogenic beliefs, testing, passive-into-active, and corrective experiences have to do with sexual fantasy? The answer is that sexual fantasy can function as a cause and effect in all of these dimensions of the clinical process. As I’ve mentioned, patients will often talk about their sexual fantasies only when they feel safe enough to do so. A great deal of psychotherapeutic work often needs to be done to reach such safety.

Understanding patients’ sexual fantasies cannot only deepen understanding of their core problems but can guide therapeutic technique in more direct ways. Sometimes a fantasy tips the therapist off as to how the patient is likely to test, and what the therapist should do when this happens. In these cases, sexual fantasies can function as a kind of operator’s manual for the therapist to provide the right interpretations and experiences that will help patients change their underlying belief structures.

Consider, for example, the case of Sue, the patient who enjoyed sexual scenarios in which she was bound and dominated. Once I understood that the function of these scenarios was to reassure her against her guilt about being too powerful and hurting a man, I anticipated that she would somehow test me to see if I could tolerate her being strong without feeling threatened or hurt. I further understood that if I became defensive or otherwise communicated that she was too much for me in some way, she would immediately detect this and would not be able to work through her conflict about being stronger than men. In other words, once I understood the meaning of her sexual preferences, I knew more about what Jan needed from me. She needed not only understanding but a certain demonstration of strength and an ability to appreciate hers. Jan did test in just this way. She began to criticize me and my ideas in an increasingly forceful manner. I agreed with her in an easygoing way when I thought she was right and held my ground—leavening it at times with humor—when I didn’t. She visibly relaxed and became more trusting of me over time.

When I understood that Otto’s pornography obsession involved his fears about becoming too identified with a depressed and aging woman, I knew that it would probably be important for me to be relatively upbeat so as not inadvertently to create the same problem in his therapy that he had in his life. As opposed to some therapists who emphasize how important it is for the patient to repeat and relive conflicts with the therapist, in my experience it is often easier for a patient to get to the bottom of a problem if it is not actively occurring in full force with the therapist. Otto would feel safer looking into his hypersensitivity to the downbeat moods of others if he didn’t have reason to experience one in me. Similarly, with George (the patient who finally left his marriage to a very unhappy woman, and who struggled with the guilty belief that separation was supposed to be painful), I also knew that if my manner was too serious or “heavy,” this would confirm his belief that he wasn’t supposed to leave his marriage unscathed or be lighthearted in any way.

Patients are extremely sensitive to the nuances of their therapist’s style and often read into it signs about how they are supposed to feel or act. To help my patients feel safe, the more understanding I have about their pathogenic beliefs—understanding that is often enhanced through knowledge of their sexual fantasies—the better able I am to anticipate certain tests in the therapy and to pass them.

Just as my understanding of sexual fantasies is based on the concept of safety, so, too, is my understanding of the process of psychotherapy. People can face painful memories, feelings, or thoughts, or brave the dangers of making changes in their core attitudes, only if it is safe to do so. Safety is the key to understanding how sex, the mind, and therapy function. It is the concept that unifies what we do in bed with what we do in therapy.

This is often particularly salient in patients who had mothers who acted highly victimized and about whom their children had to worry and feel guilty. Almost inevitably these patients turn passive into active and act like victims in their therapy. The “test” becomes to see if the therapist will, indeed, feel guilty and worried as the patients did when they were children.

A female therapist consulted me about the case of a patient, Rick, who had been in therapy for nine months for treatment of depression when he revealed that when he traveled on business, he often tried to hire a prostitute who would urinate and spit on him. These activities allowed him to become sexually aroused. Despite his therapist’s prodding, Rick had provided her with scant information about his childhood, except for describing his father as “impatient” and his mother as “quiet.” Based on my understanding of sexual fantasies, I made a series of observations and predictions about Rick and the probable course of his therapy that turned out to be true. I said that I thought that Rick had probably had a weak or masochistic mother who frequently led the patient to believe that he was abusing her, hurting her in some way—in effect, implying that he was “pissing” on her. In his sexual fantasy Rick identified with his mother, the martyr who was pissed and spat on. This role mitigated his guilt and enabled him to get turned on. He was now the victim, not the victimizer. I said that I thought that the fantasy was an antidote to his guilt and that was why it was exciting. His therapist eventually was able to confirm these speculations. The patient’s mother, it turned out, had had to give up her career as an actress when she got married and became pregnant with the patient and never let either her husband or son forget how much she had sacrificed.

Additionally, I was able to make certain predictions about this patient’s therapy. I said that I thought that either the patient would try to make the therapist feel that she was hurting him, a passive-into-active test, or else would somehow devalue or “piss on” the therapist. In either case, by understanding the underlying dynamics of the case, the therapist would have a pretty good sense of how she was supposed to respond in order to disconfirm the patient’s pathogenic beliefs and make him feel safe. If he tried to make her feel worried and guilty, she should be careful not to do so; and if he tried to put her down, she should definitely stand up for herself and not in any way let him infer that she was feeling victimized or martyred. My colleague was able to confirm many of these predictions. The patient was subtly degrading to the therapist, frequently criticizing her office, choice of art, the way she dressed, and her intelligence, and seemed quite relieved when the therapist was robust and confident in her responses.

The case of Glenn represents another example of a therapy that was greatly facilitated by understanding the patient’s sexual fantasy. When Glenn, the medical researcher in chapter 3, told me that he liked to sit at the window of his office at night and “cruise” men who came by, inviting them in for anonymous sex, we were able to figure out that this scenario was an attempt to counteract his feelings of disconnectedness in a way that also ensured he wasn’t responsible for making the other person happy. Armed with this insight, I was also able to make some educated guesses about how Glenn might use therapy, and how I might best help him. His sexual fantasy reinforced my initial impression that he might have difficulty connecting with me and would worry that he wasn’t satisfying me by being a “good enough” patient. As a result, I thought that it would help him feel safer if I counteracted these worries by being particularly active in reaching out to him and by expecting very little in the way of therapeutic “progress.” Although I fully planned to analyze these feelings with him, if and when they came up, I also knew that in order to make it safe enough for him to explore them, I should also attempt to counteract them in practice by actively connecting with him in a way that conveyed that whatever he did in therapy was satisfactory.

In this sense, Glenn’s sexual fantasies and preferences informed my technique. They provided crucial information about his pathogenic beliefs and about the dangers that he was attempting to overcome, which I could use to provide him with more of what he needed in therapy. Of course, in Glenn’s case, as with all of my patients, when I have hunches or make predictions about what I need to do to make a patient feel safe in therapy, I rigorously attempt to keep an open mind, to allow fully for the possibility that I’m wrong and might need to change direction completely. In my discussion of testing, I said that a patient will respond to a passed test by moving forward, and he or she will respond to a failed test by becoming stalled. In my emphasis on how patients respond to my intervention, I was indirectly emphasizing a guiding principle of my work—that I attempt to use the patient’s responses to what I say and do as the ultimate arbiter of the value and truth of my theories.

It is enormously useful for therapists to constantly generate hypotheses about what is going on in their patients, inside and outside therapy, because theories, even provisional ones, help us to explain what we’re seeing and feeling. In fact, one of our functions as therapists is to help our patients develop better, more accurate, and more useful theories about themselves in order to be able to make healthier choices in their lives. So generating and testing hypotheses and predictions about the patients that I’m treating are essential to my clinical approach. It is equally crucial for therapists to be “empirical” in their work, that is, to use their patients’ responses to their interventions as important measures of whether these interventions are right or wrong, and to use patients’ therapeutic progress as the ultimate barometer of whether or not the therapist is doing the “right” thing.

SEXUAL FANTASIES ARE DIFFICULT TO CHANGE

My approach to patients’ sexual fantasies is identical with my approach to everything else important they tell me. I help them explore the meaning of their daydreams and preferences, the feelings and beliefs they are both expressing and counteracting, and attempt to use these as a window into their deepest levels of psychological functioning. Whether or not sexual fantasies and preferences are used to explain someone’s pathogenic beliefs or are themselves explained by such beliefs, their appearance in therapy offers patients a useful tool for understanding and growth. In my clinical experience, however, sexual fantasies and preferences, while understandable in exactly the same terms as any other aspect of the mind, have certain unusual features. One is that they are very difficult to give up or change.

I can and do certainly help my patients feel less ashamed of their thoughts and wishes. Often, when patients better understand their fantasies as creative and adaptive solutions to problems of safety, their self-esteem is enhanced, and they then are able to share their daydreams and wishes with their partners without shame or fear of rejection. Many patients have found that the result of this increased communication is a better sex life. They discover that their partners are willing and sometimes eager to participate with them in enacting their fantasies.

Other times, increased awareness and understanding of the mental mechanisms behind a sexual preference may make it more flexible, less obligatory and rigid, and more open to compromise and negotiation. Perhaps a “top” becomes willing sometimes to be a “bottom,” a man fixated on Asian women becomes willing to consider others, a woman who wants to be thrown on the bed and ravished becomes more willing to reciprocate, or a man who can get aroused only by penetrating a woman from the rear becomes able to get aroused by the missionary position. People change the form and content of their sexual lives in response to psychotherapy all the time.

Nevertheless, I think that, in general, the core conditions required for maximum sexual arousal are very difficult to change significantly. Although people may become less ashamed, more communicative, and more flexible about the fantasies that turn them on, it is unusual that they give them up completely. The man who prefers to be dominated sexually by women rarely becomes a man who prefers to be dominant. He may be better able to enjoy playing the dominant role, but he won’t enjoy it quite as much. The man who is especially preoccupied with young women may become more able to get aroused by his wife or women his own age, but he will still usually have a “thing” for youth. The woman who enjoys seducing men in authority may, as a result of analyzing the meanings of this scenario, become sexually responsive to someone “ordinary,” but she will still be likely to gravitate toward powerful men in her choice of partners. The woman who finds herself especially drawn to men who have a rough or even a mean “edge” to them may work through her guilt enough to enjoy the love of a kind man, but it is equally likely that she will still choose a partner who has an edge, albeit a much softer one. In others words, as a result of understanding the meanings of their sexual fantasies, as well as working through the pathogenic beliefs that these fantasies are designed to overcome, people may become much more varied in their sexual repertoires, but they don’t give up their old fantasies completely.

Further, while insights into the meaning of their fantasies might be put to good use by patients in changing their lives outside the bedroom, their secret preferences inside the bedroom usually don’t change as much. After one man I knew came to understand that his pleasure in being tied up by his wife during sex reflected an attempt to undo his image of women as sad and weak, his guilt toward women in general was reduced, and he was able to assert himself more in his marriage and at work. His primary sexual preference, though, was still to be restrained and dominated by a woman.

What accounts for the relative intransigence of sexual excitement to change in psychotherapy? Why can people turn the rest of their lives around, sometimes radically, as a result of understanding their pathogenic beliefs, while at the same time they hold on to the private sexual scenarios that turn them on?

It is not as if, as a therapist, I don’t frequently see patients whose psychology changes very little in therapy or who may improve one part of their lives and not others. Personality, after all, is relatively stable over time. Radical transformation is the exception and not the rule. Patients who tend toward shyness at the beginning of therapy, while becoming more assertive over time, will usually still be relatively mild-mannered at the end. Type A personalities, people who are obsessively driven to work and succeed, can be tremendously helped to relax and reduce their perfectionism by psychotherapy, but it is relatively rare for such a person to become a laid-back Type B after treatment. Sometimes, I see people in therapy whose progress is not only slow but tediously so. If someone consults me who happens to be paranoid, suspicious of my motives, skeptical about the ability and willingness of other people to help him or her, that patient’s treatment will proceed very slowly. The intransigence of certain personality traits and problems is a common finding in psychotherapy and one that most therapists come to accept. People get formed in the crucible of the interaction between their families and their genes and, once formed, are not infinitely mutable. Therefore, the fact that sexual fantasies don’t tend to dramatically change should not be surprising.

Yet, to me it still is. Why do sexual preferences endure despite the fact that the underlying psychological reasons for their creation may be eliminated? Why do patients manage to change a particular pathogenic belief and, as a result, reduce their work inhibitions, improve their marriages, and become more creative but still strongly prefer a sexual fantasy that arose as an attempt to master that same pathogenic belief? The main reason that sexual fantasies and preferences don’t tend to change much, even as the motives for their creation do, is because they’re pleasurable. Here is one example. A woman who was treated by a colleague of mine had sexual fantasies that were primarily exhibitionistic in nature. She liked to imagine that she was the object of the sexual lust of a group of rough male construction workers. In her fantasies she drove them wild with desire and eventually succumbed to some kind of group sex with them. In the real world this woman also invested a great deal of time, energy, and money into looking sexy and enjoyed the feeling that she was being admired by men wherever she went.

Upon analysis it turned out that her fantasies were arousing because they overcame feelings of shame and rejection that she had felt growing up. Because of particular experiences in her family, she had always struggled against the belief that she was undesirable. As the object of intense sexual attention and adoration, however, she momentarily disproved this belief and was therefore able to get safely excited. After the understanding that she acquired in therapy, she became more interpersonally confident, felt worthy of better relationships, and worried a bit less about her appearance. Yet her primary sexual fantasies remained roughly the same: she was the object of intense, uncontrollable male sexual desire. She still felt a special thrill at the attention she would attract in her real life as well. While other aspects of her life had changed quite a bit, her erotic predilections had barely changed.

Why should they? We usually don’t have an investment in altering the scenarios that arouse us. While it is true that the same pathogenic beliefs that give rise to sexual fantasies also produce inhibitions in other areas of our lives, the difference is that sex feels good, while frustrated ambitions and conflicted relationships feel bad. We not only have little incentive to transform the conditions under which we feel excitement but, even if we wanted to, changing them would be difficult. It is as if a certain image, body type, sexual position, or script has always “worked” to produce excitement for us, and there is little reason to change it. Pleasure is a powerful reinforcer and helps cement the desirability of particular sexual fantasies early in life. Pleasurable sexual fantasies are more than a simple habit but less than a compulsion.

The fact that sexual preferences persevere even as their psychological foundations may change does not mean that their meaning and function change. Sexual preferences are still based on a need to establish conditions of safety so that excitement can emerge and flourish. A man who prefers to be rough and dominant in bed because his partner’s sexual arousal reassures him against his pathogenic belief that his aggression is highly destructive may use therapy to understand and lessen his irrational tendency to feel guilty, expand his sexual repertoire to include a gentler mutuality, and free up the rest of his life considerably. He still may prefer a dominant sexual role and for the same reasons: to master his guilt, but a guilt that is now a whisper rather than a roar. The fact that his domination scenarios have provided so much pleasure in the past ensures that they will be his preferred scenario in the future. His guilt has been mitigated enough to change his life, but it is still enough to trigger his time-tested and successful solution.

Sometimes, of course, patients might be highly motivated to change their preferred sexual fantasies because, while they may provide pleasure, they are also accompanied by pain. If this man’s partner doesn’t get aroused by his rough sexual aggression, then his relationship will suffer as a result, and he might be motivated to use therapy to change his preferences. Or if someone’s sexual interests feel anxiety ridden, compulsive, or are socially dangerous (as is often the case with Peeping Toms, exhibitionists, pederasts, or even Internet sexual addicts), then there might be enough distress for someone to want to interrupt his or her normal channels of sexual arousal.

Sexual fantasies are used to deal with idiosyncratic versions of universal human conflicts. Who among us hasn’t felt restrained by some form of guilt, worry, shame, rejection, and helplessness in our lives? Who among us hasn’t felt guilty about having more satisfaction in life than our loved ones have? Who hasn’t felt some form of separation guilt? Who can say that he or she has never felt inferior or had doubts about his or her worth? These are inherent aspects of contemporary life and continue to exist in some form regardless of how well psychotherapy succeeds in tempering and dampening their toxic effects. Therefore, even after someone is “cured” in therapy, underlying conflicts still exist that imperil sexual excitement. Thus, his or her favorite routes to the safe experience of pleasure, reinforced countless times over countless years, will always occupy a special place in that individual’s sexual repertoire.

A friend of mine recently asked me if there were any sexual fantasies, preferences, or behaviors that I thought were simply immoral or otherwise unacceptable. I had to think for a moment before I answered. I realized that I had two very different responses, depending on whether or not I was responding as a therapist. As a citizen and a human being, I believe that any form of sexual interaction that is nonconsensual is immoral, including any explicitly sexual behavior between adults and children. As a therapist, however, I think and feel differently. If I were treating perpetrators of rape or child abuse, while not forgetting my moral revulsion, I would attempt to put it aside and, instead, understand the processes by which such coercive behavior becomes arousing and the beliefs and feelings that it is attempting to correct. My clinical approach to someone whose fantasies or preferences I personally find bizarre or reprehensible would be identical to my approach to fantasies and preferences that I consider more familiar, morally acceptable, or “normal.” In other words, I would focus my attention entirely on understanding and changing the underlying conflicts that gave rise to the behavior that I might personally feel was wrong.

The issue for me as a therapist is not whether a sexual fantasy is bad, immoral, or socially unacceptable, but whether the underlying issues that the fantasy is attempting to resolve are damaging in some way. If a patient tells me that getting whipped turns the person on, or that he or she likes to be urinated on, or someone tells me a fantasy of raping a neighbor or of being raped by the neighbor, I may feel personally bewildered by the appeal of these scenes, but my primary concern isn’t that the sexual scenario is pathological (provided it remains a fantasy or is enacted consensually). My concern is that the anxiety or guilt the sex is overcoming is pathologically interfering in the patient’s life.