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Book Reviews

Barriers to Loving: A Clinician’s Perspective

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Barriers to Loving is a 133-page summation of Stephen Levine’s scholarship, practice, and teaching in the field of love and sexuality. It is directed at a wide audience including psychiatrists, other therapists, and trainees. It is highly recommended as a practical clinical guide and as a volume that introduces other areas such as philosophy (Plato, Aristotle) and theology (Buber, C. S. Lewis) to the questions proposed. A great amount of information and wisdom is imparted in these few pages.

The following topics are considered: why we avoid talking and thinking about love, a compendium of love’s pathologies, courtship, diminishment of lovability, inability to express love, sexual excess, infidelity, the scientific study of love and sexuality, therapy, and the definition of love. All of these are clearly presented.

The tone of the book is optimistic for therapists without overstating the strengths of our knowledge at this time. Certainly, Levine is not like the French psychoanalyst and philosopher Lacan, who wrote, “Love is giving something you haven’ t got to someone who doesn’ t exist” (p 3). Nor does the book emphasize Freudian psychodynamic causality. Levine is far more concerned with pathogenesis or process as an explanatory mode. He is not impressed with the depth of the scientific knowledge about sexuality and love, although a few biological studies are included. This book is more about clinical utility than the DSM formulations. He believes that our emphasis on symptoms leads us directly to diagnosis and then medication selection. The primary goal in therapy, he expresses, is to clarify the existing pathologies and the way in which the patient or couple arrived at the current point. Description, rather than causality, definitive diagnosis, and medication, is his focus.

Psychiatrists and other therapists seem to avoid discussion of love in their work. We view as our responsibility the management of disorders of thinking, feeling, perception, and behavior. The focus is on psychopathologies rather than failure at love processes. Levine differentiates etiology from pathogenesis: “The etiology of disorders is discussed in textbooks, research articles, and lecture halls; the pathogenesis of a patient’s disorder is discussed in therapy rooms” (p 2).

Failed love processes are presented in the broad culture and do not appear sophisticated enough to be specialty knowledge of mental health professionals. We usually deal initially with patients’ major emotional distress and do not focus on the events that created the crisis. We often believe that the personalized nature of love processes is beyond the precision of science. Sometimes we do not distinguish between pathologic and ordinary disappointments in love. We assume that love issues are related to deeper developmental issues, which we prefer to discuss.

The book is a search for clinical answers about love, and the basic question is, “What is love?” Levine believes that love entails pleasure and great interest in the partner, sexual desire, and optimistic behavior (p 129). He believes that good therapists pay close attention to these attitudes or their lack.

At the heart of this book are love’s pathologies. The general classification includes impediments to a loving relationship. Several categories of these impediments are physical disabilities, cognitive disabilities, major mental illness, gender dysphoria, character pathology, and select paraphilia. Some of these categories also overlap with impediments that decrease the patient’s lovability, impediments that limit the patient’s ability to express love, and challenges of love problems emerging during courtship (pp 10-18).

Treating problematic sexual excess or sexual addiction, according to Levine, requires a great deal more knowledge of character pathology than is presented in DSM-5. The character pathology usually represents maladaptive rigidity. His therapeutic work with these patients, again, focuses on pathogenesis rather than much earlier developmental issues. Sexual excess seems to involve patients who have given up on love after divorcing or becoming widowed; those who never tolerate sex, with its emotional complexity; those who were introduced to pornography before puberty, preventing an honest courtship; those who separate sex from marital love; those stimulated by lack of a relationship; and those with persistent adolescent erotic obsessions. These issues are often overlapping, complex, and difficult to treat. The therapist can be alert to them and pursue them when the patient agrees. The excesses and other pathologies can lead to infidelities, as Levine points out.

A strong argument is presented for the benefits of monogamy: preserving the couple’s mental, physical, social, and economic health; facilitating children’s emotional development; preserving the continuity of relationship with family and friends; and preventing pessimism about the possibility of marital happiness in all concerned. As Levine summarizes, “The institution and maintenance of monogamy is protective of family structure” (p 82).

This volume is especially useful with regard to taxonomy. Levine presents the Triangular Subtheory of Love, which classifies several types of love:

Friendship—intimacy without passion or commitment

Infatuation—passion without intimacy or commitment

Empty love—commitment without intimacy or passion

Romantic love—intimacy and passion without commitment

Companionate love—intimacy without passion and commitment

Fatuous love—passion and commitment without intimacy

Consummate love—intimacy with passion and commitment (pp 101-102)

There are several other classifications of love, but for all, the hope would be in the heuristic value for clinical and basic study, for social scientific study, and for enhancing the awareness of patients and therapists.

Levine’s advice for trainees is to love their work, love being a student, be interested when patients talk about love, and replace much psychodynamic thinking with the concept of pathogenesis. This focus on pathogenesis removes some mysteries and helps to clarify impediments to loving. Levine asserts that etiology is overemphasized today, but that we are not always aware of this. He cautions therapists not to catalog all symptoms through the DSM cognitive filter (pp 110-114). This book is a great extension of and corrective for DSM. Love is numerous processes. For example, courtship leading to love is usually a result of repeated intimate conversations. Love is a management process by the couple. Love is less speech, though, than it is a series of acts of compassion, comprehension, and accommodation (pp 110-114).

Love problems include decathexis or devitalization in committed relationships (p 116). It is much easier to love a partner who shows happiness rather than the negatives in the patient’s being. Otherwise, there is growing loneliness. Clinicians can be distracted from love problems by the emphasis on psychiatric diagnosis. Archetypical psychopathologies of love are violence, jealousy, and loss of desire (pp 118-119).

Individual therapy can address these common themes: uncertainty about the nature of love; the differences between a partner’s feelings, behavior, and words; and recognition of disappointments in a partner (p 120).

Talking about these themes is often prevented by the patient’s moral commitment to love one’s partner, the wish to appear in a good light to the therapist, and uncertainty about the meaning of one’s unstated feelings. There is no lack of issues and processes to examine in therapy (p 120).

When therapists discuss love problems, diagnosis may come up and lead to selection of medication. Or, cognitive therapy may be commenced in a way that shows minimal regard for hearing about the patient’s real feelings. Therapists can instead acknowledge the patient’s struggle to love as an important concern. Therapists cannot claim to know all aspects of love, but Levine suggests that therapist and patient work together on solutions. For some patients, there is no wish to discuss their love problems. Therapists will wait for another session to pursue these issues.

This book is an excellent taxonomy or compendium of the various pathologies of love and sexuality. It is useful for clinicians, teachers, researchers, and all who are involved in mental health care. Some relevant aspects of the humanities as well as neuroscience are presented to assist when clinical knowledge is incomplete. The clinical paradigm shifts from pure dynamic, cognitive, or biological approaches to include a detailed emphasis on more recent pathogenesis of the distress. I recommend Barriers to Loving highly.

Arthur M. Freeman III, MD

amfreeman3@gmail.com

Author affiliations: Tulane University School of Medicine, New Orleans, Louisiana.

Potential conflicts of interest: None reported.

Volume: 76

Quick Links: Psychiatry

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