Isn’t intimacy a good in itself, a bundle of warm emotions that promote caring attention? Drawing a continuum from impersonal to intimate helps us avoid some common, morally tinged confusions in these regards: intimacy as emotion, intimacy as caring attention, intimacy as authenticity, and intimacy as an intrinsic good. Many analysts are tempted to define intimacy by the emotions it typically evokes, such as intense, warm feelings. This is a mistake. Intimate relations, from gynecologist-patient to husband-wife, vary systematically in how they express or inhibit emotions. Nor (as most doctors and most spouses know well) does intimacy exclude anger, despair, or shame. The word intimacy also often calls up caring attention. Many intimate relations include a measure of care: sustained attention that enhances the welfare of its recipients. But in other intimate relationships the parties remain indifferent to each other or even inflict damage on one another. Abusive sexual relations, for example, are certainly intimate, but not caring. Such relationships supply risky information to at least one party and thus entail trust of a sort, yet do not include caring attention. Intimacy and care do often complement each other, but they have no necessary connection.
What of authenticity? Analysts of interpersonal relations frequently distinguish between real and simulated feelings, disparaging simulation with such terms as pseudo-intimacy and emotion management. They often draw on the idea that routinization of emotional expression in such jobs as waitress, flight attendant, or store clerk deprives the social relations in question of their meaning and damages the inner lives of the people involved. In such a view, truly intimate relationships rest on authentic expressions of feeling (see, for example, Chayko 2002; Hochschild 1983). The closer we look at intimacy, however, the more we discover two flaws in this reasoning. First, no single “real” person exists within a given body; feelings and meanings vary significantly, understandably, and properly from one interpersonal relationship to another. In fact, the feelings and meanings that well up regularly in mother-child relationships can seriously hinder relationships between lovers. Second, simulation of feelings and meanings sometimes becomes an obligation, or at least a service, in some sorts of relationships. Just consider intimate relations between adult children and their aging parents, or between nurses and their terminally ill patients.
Intimacy, finally, often looks like a good in itself, especially to social critics who deplore the loss of intimacy in an impersonal world. Yet a little reflection on undesirable uses of intimacy—date rape, blackmail, malicious gossip, and more—underlines two more facts about intimacy. First, it ranges from damaging to sustaining, from threatening to satisfying, from thin to thick. Second, it matters sufficiently to its participants and to third parties that people constantly draw moral boundaries between proper and improper uses of intimacy. Yes, intimacy bears a moral charge, but precisely because different sorts of intimacy vary in their moral qualities. When people distinguish between “true” and “false” intimacy, treating the “true” kind as a good in itself, they are making just such distinctions.
In all intimate relationships, accordingly, participants and observers take great care to distinguish them from other relationships that share some properties with them. As we will see, relations of sexual intimacy frequently include transfers of money. Those involved, however, are careful to establish whether the relationship is a marriage, courtship, prostitution, or some other different sort of social tie. In the absence of sexual intimacy, people also establish fine distinctions, for example, among caring services provided by physicians, nurses, spouses, children, neighbors, or live-in servants. In each case, participants and observers frequently engage in fierce debates about the propriety of different forms and levels of compensation for the caring attention involved. They often ban certain combinations of relations, transactions, and media as utterly improper. Later chapters of this book will provide innumerable examples of variation and moral boundary drawing. They will even propose explanations for variation and moral boundary drawing in intimate social relations.
Take the case of psychotherapy. This sort of relationship is necessarily delicate, since effective treatment depends on the quality of the relationship itself. A semiofficial American guide to legal issues in psychotherapy makes the following recommendations concerning payment systems appropriate for a therapeutic relation:
“Special” billing arrangements make the patient “different” and are associated with an increased opportunity for misunderstanding (real, displaced, or projected) and, when countertransference rears its head, improper or substandard care (cf.
treating VIP patients). Barter arrangements can be specially problematic. Money is a very consistent medium of exchange, and patients’ reactions to it are reasonably predictable and understandable by the psychotherapist (and judge or jury, if it comes to that). Trading clinical services for other items, such as goods or services, although not illegal or necessarily unethical, complicates treatment and increases the probability of boundary and transference-countertransference problems. The same applies to free or discounted care. (Reid 1999: 60)
The guide delineates which media (legal tender, no “special billing”) and transfers (compensation, not barter or gifts) correspond to the therapist-patient relationship.
In addition, the manual explicitly differentiates between permissible and impermissible therapist-patient relationships. It specifically calls attention to markers for the boundaries between permissible and impermissible relations. When it comes to sexual relations, some “red flags” symbolizing improper “boundary violations” include the following:
• Avoiding documentation of incidents or parts of the treatment that reasonable therapists would be expected to note in the chart (for example, not mentioning gifts, telephone calls to or from the patient, or sexual material, or the clinical discussion they should generate).
• Seeing patients of the opposite sex alone in a deserted clinic or office, especially during odd or evening hours.
• Changing session hours or meeting circumstances to such a setting without documenting a good reason.
• Seeing patients alone in their homes, or yours.
• Avoiding supervision, consultation, or documentation with one or two female patients when such activities are routine for other patients.
• Locking the office door during therapy sessions. (83-84)
The guide also delineates nonsexual therapist-patient “boundary violations,” including accepting substantial gifts or compensation
beyond the routine fee from a patient or profiting from a patient’s “inside information” on an investment. “Your usefulness to patients,” it declares, “lies in your clinical skills and your separation of your professional role from other roles better found elsewhere in their lives” (89-90).
In Ontario, a comparable Canadian text for therapy-providing psychologists goes even further. It provides an actual matrix of what the authors identify as problematic “dual relationships.” Dual relationships, according to the manual, not only threaten the therapeutic bond but also bring therapists the risk of legal penalties. Table 1.1 presents excerpts from that elaborate matrix. Although one might have thought that sexual predation would constitute the major risk in such relations, the matrix has two striking features: first, it warns against a wide variety of nonsexual relations as risky, and second, sometimes the risk to the therapeutic bond arises from previously existing relationships rather than the other way round. As in other professional-client relationships, psychotherapists and practicing psychologists establish a complex but relatively clear set of distinctions among appropriate and inappropriate matchings among relations, media, and transactions.
What explains the proliferation of distinctions, practices, stories, and moral injunctions concerning the interplay of economic transactions and intimacy? Why do participants, critics, moralists, jurists, and observers worry so much about finding the “right” sort of compensation for their various intimate relations? What sorts of social effects are participants and observers producing, or at least trying to produce?