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Clinical and Research Reports |
Received October 7, 1999; revised August 3, 2000; accepted August 24, 2000. Address correspondence to Dr. Koo, 509 N. Sepulveda Boulevard, Suite 202, Manhattan Beach, CA 90266.
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Abstract |
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Key Words: Transference/Countertransference • Gender
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Introduction |
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We shall never be able to do without a strictly regular, undiluted psychoanalysis which is not afraid to handle the most dangerous mental impulses and to obtain mastery over them for the benefit of the patient.
—Sigmund Freud, SE, 12:171
Sigmund Freud, in his hallmark paper "Observations on Transference-Love,"1 was the first to describe "transference love" and to theorize about its meanings in the psychoanalytic process. Since Freud's time psychoanalytic literature has continued to address the delicate subject of love, sexual and sublimated, in the transference, but there has been a notable paucity of literature dealing with male patients' erotic transferences to female therapists. It has been suggested that full erotic transferences do not develop in male patients and that erotized transferences rarely, if ever, occur. Personal experience during training, the noted lack of case reports on male erotized transference, and my observations regarding the universal difficulty fellow clinicians have in handling erotic transferences aroused my interest in this subject. The purpose of this paper is to present a case report documenting erotization in a male patient–female therapist dyad and to review current theories on the etiology, therapeutic significance, and treatment strategies indicated for the erotized transference.
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DEFINITIONS |
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As defined by Blum,4
Erotized transference is a particular species of erotic transference, an extreme sector of a spectrum. It is an intense, vivid, irrational erotic preoccupation with the analyst, characterized by overt, seemingly ego-syntonic demands for love and sexual fulfillment from the analyst. The erotic demands may not seem unreasonable or unjustified to the patient..., [and] the urge toward real fulfillment, rather than fantasied substitute gratification, [is] often associated with an altered sense of consciousness and reality. (p. 63)
Bolognini5 characterizes the erotized transference as "stubborn, irreducible, ego-syntonic, incapable of accepting surrogates, and of unforeseen and early onset" (p. 74). Erotization impairs the patient's reality testing and critical judgment so that the patient wants fantasy to be reality,1 and the capacity to acknowledge the "as if" quality of the transference situation is lost.6
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PATIENT CHARACTERISTICS |
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Sandler and colleagues3 contend that erotization corresponds to a severe disturbance of the sense of reality, is indicative of the severity of illness, and is usually manifest in borderline cases or in cases of ambulatory schizophrenia. Blum4 maintains that these patients have primary preoedipal conflicts rather than core oedipal issues, and that they lack the ego capacity for neutralization and delay.
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IS EROTIZED TRANSFERENCE TRULY RARE IN MALES? |
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 TopAbstractIntroductionDEFINITIONSPATIENT CHARACTERISTICS IS EROTIZED TRANSFERENCE TRULY... ETIOLOGICAL FACTORSTHE ANALYST'S ROLE IN...TREATMENT TECHNIQUES TO DEAL...CASE REPORTDISCUSSIONCONCLUSIONReferences |
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Despite the evident lack of reported cases, many authors contend that erotized transference in the male patient is not such a rare phenomenon. Several factors may contribute to the dearth of documented cases. Gabbard12 stresses the extreme discomfort the expression of such erotic feelings arouses in therapists, and Fuerstein13 cites therapists' needs to deny their own sexual feelings toward patients. Person14 suggests that sustained erotic transferences in male patients with female therapists are more often observed in older men with younger women, a dyad most common in training situations, and that the youth and inexperience of the therapist result in these cases not being reported in the literature. I believe that the male therapist, due to social/gender issues, may be more comfortable than the female therapist discussing and documenting cases of erotized transference. Historically, women have struggled to achieve status as professionals in our society. To be aggressively sought after as a sexual object, while simultaneously rejected as a competent and effective therapist, may disproportionately threaten the female therapist's professional role in society.
Authors who claim that erotized transferences in male patients are rare have offered theoretical explanations. Person14 believes that the male patient who allows himself to feel erotic urges toward his female analyst only emphasizes his need for her, a dependency that represents weakness. By desexualizing the analyst, the male patient abolishes the power inequity inherent in the treatment relationship and permits himself to experience more affectionate feelings. Lester9 suggests that the infrequency of erotized transferences in male patients may reflect a particular vicissitude in the transference. Specifically, she maintains that
The fear of the powerful pre-oedipal mother re-enacted in the transference...may threaten the stability of male gender and self-identity, and inhibit strong erotic fantasies toward the oedipal mother. The working-through of pregenital struggles... is played out over dominance-submission or sadistic-masochistic issues...[that] overshadow erotic genital impulses toward the mother. (p. 284)
Both Fuerstein and Person suggest that sociocultural attitudes about gender roles limit the development of erotic transference in men. Fuerstein13 believes that the nonaggressive and nurturing stance imposed on the female analyst by her gender/social role may conflict with the probing manner or necessary acceptance of herself in the more aggressive context required to explore and work through an erotic transference:
In sum, when the female analyst is seen by the male patient either as the seductive harlot, frightening Medusa, strong paternal rescuer, or the ever-flowing maternal breast, her countertransference responses will be crucial in helping him to integrate these split-off object representations. She must be ready to perceive herself as the bad breast, aggressor or father, as she is the good breast, nurturer or mother, in order to further the evolution of the erotic transference in particular and the expansion of the working-through process in general. (p. 69)
Person14 suggests that a female analyst's own inhibitions, secondary to cultural prohibitions about openly acknowledging sexual or erotic fantasies, subtly prevent inquiries into the patient's defenses against erotic feelings, and that the absence of such inquiries results in a lack of development of erotic transference.
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ETIOLOGICAL FACTORS |
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Blum4 suggests that an erotized transference has multiple determinants and may defend against many unconscious conflicts. He emphasizes, however, the pathogenic role of seduction and trauma, and he notes common genetic factors in many cases: "sexual seduction in childhood, instinctual overstimulation with deprivation of parental, phase-appropriate protection and support, intense masturbatory conflict, family tolerance of incestuous or homosexual behavior... and revival and repetition of precocious and sexual activity in adolescence" (pp. 67–69). Person14 observes that erotic transferences in men occur more frequently in those with strong bisexual identities or homosexual conflicts, and that the transference may serve as a defense against a threatening homosexual longing. Bolognini5 believes erotization defends against separation and abandonment: "It is an attempt at psychotic restoration of a state of narcissistic fusion with the preoedipal object, with disavowal of the separateness of the object itself, in a climate dramatic and grandiose" (p. 74). Solomon17 points out that a preoccupation with sexual matters, in fantasy or in acting out behavior, may be entirely separated from meaningful human relationships and suggests that the erotized transference may defend against a true object relationship.
In addition to exploring the defensive aspects of erotization, significant attention has been paid to understanding early life relationships as a key factor in the patient's tendency to develop an erotized transference. Saul connects the erotized transference with real frustrations in early life relationships.3 Intersubjectivists, viewing the erotized transference as a product of a unique transaction between the patient and the analyst, assert that erotic feelings prevail in the transference as a consequence of anticipated or experienced selfobject failures. Patients seek erotized replacements for missing or unsteady selfobject experiences and, believing themselves unworthy of love, offer themselves as sexual objects in order to preserve the relationship with the analyst.18 Rappaport6 theorizes that patients who never experienced love in their own lives would not have the capacity to be hungry for something they did not know. These patients, however, are hungry for what they did experience sporadically and inconsistently: contact. The erotized transference serves their wish for direct physical contact.
Despite the patient's demonstrations of outward love, Menninger and Hulzman15 warn the analyst not to forget the aggressive component involved in the erotized transference. Extreme love is seen, in part, as a means of protecting the therapist from hostile feelings, and the transference resistance is seen as stemming from underlying impulses of hatred.3
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THE ANALYST'S ROLE IN EROTIZED TRANSFERENCE |
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The traditional view of transference as simply the reenactment of past relationships or as the reexperiencing of childhood events has been altered during the evolution of psychoanalysis, so that more contemporary theorists portray transference also as a construction in the here and now that is influenced significantly by the analyst's personality. Transference is thus not a product solely of the patient's past and psychopathology, but also a product of the input from the analyst.19 Given this broader definition, one is forced to inquire about the possible role of the therapist in erotization.
Greenson7 believes that the personality and skill of the analyst influence the order and intensity of the patient's transference reactions as well as the ease and/or difficulty in working through. He suggests that subtle, longstanding, repeated, and unrecognized errors in technique, stemming mainly from countertransference reactions and an incorrect understanding of the patient, are responsible for intractable transference reactions.7 Eber18 states that the theoretical orientation of the analyst has a significant impact on transference manifestations and that there is an increased likelihood of erotized transference when the drive model predominates. He also asserts that erotic demands from the patient may be evoked by the analyst's seductive behaviors or may result from a masochistic compliance with the sadism of the analyst.18 Swartz relates erotized transference to the failure of development of an adequate treatment alliance.4 The possibility that the analyst may be a significant factor in the development of the erotized transference warrants a stronger focus on discussions of erotic transference, both in the literature and in the training of therapists.
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TREATMENT TECHNIQUES TO DEAL WITH AN EROTIZED TRANSFERENCE |
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Freud forecasted grave consequences of gratifying a patient's sexual longings. Many key figures in psychoanalysis, however, did become sexually involved with their patients: Carl Jung with Sabina Spielrein, Otto Rank with Anaïs Nin, August Aichorn with Margaret Mahler, and Frieda Fromm-Reichmann with Erich Fromm.12 Despite this history, I do not imagine that any modern analyst would suggest satisfying a patient's sexual demands. One hopes that the analyst of today is prevented from succumbing to erotic temptation by professional ethics, morality, and technique.5 It is understood that, while encouraging indulgence and play in fantasy, the analyst should insist that, however urgent the patient's desire for actual bodily contact, the work remain exclusively within the domain of fantasy and words.19
Swartz8 suggests that attention paid to associations and to the patient's general behavior and appearance during the initial interview may warn the analyst about the potential for an erotized transference. An initial interview flooded with sexual material and lacking in the socially expected modesty in discussing such material is cited as an important warning signal. The nature and sequence of material during subsequent sessions may provide clues: the previously content married man who begins to report marital dissatisfaction or the single man who portrays all dates as boring may be on his way to erotizing the transference. Another unfavorable prognostic sign is the analyst appearing as him- or herself in the patient's first dream: "An early dream of this type indicates that the patient is unable to differentiate between the analyst and a significant person of the past or that the analyst in his appearance and behavior possibly resembles such a person too closely" (p. 311).8 The patient thus demonstrates a decreased capacity to distinguish reality from transference phenomena. Any premonition of the potential for an erotized transference should signal the analyst to be particularly alert to avoid speech, manner, conduct, office, and hour arrangements that could potentiate a sexualized relationship.
As suggested by Freud, Kumin20 believes the analyst must accept the patient's sexual desire without seductiveness or avoidance. Gabbard12 reminds us that powerful longings for sexual gratification discombobulate the analyst and that the optimal technical approach depends on the analyst's ability to recover his or her bearings. The analyst must achieve a proper balance between sympathetic identification, without which one cannot understand the patient, and objectivity, without which one cannot do the professional therapeutic work.21 Achieving this balance, as well as a certain level of comfort with the countertransference feelings, permits the analyst to derive the correct interpretation to reduce the patient's sexual desire and resistance.21 Rappaport6 stresses that the analyst faced with an erotized transference must be especially watchful for any blind spots in his or her own consciousness. Saul21 emphasizes the repressed hostility intrinsic to the patient's sexual desires and believes that effective analysis of this hostility will aid the patient in obtaining true love and sexual satisfaction in real life.
As with Freud, Rappaport6 and Swartz8 emphasize the necessity of constant reality testing in the treatment of the erotized transference. Per Gabbard,12 in the erotized transference the "as if" nature of the psychoanalytic situation is lost, and it is the analyst's burden to restore the sense that the patient's feelings are both real (i.e., new feelings associated with the analytic relationship) and not real (i.e., displaced feelings from an old object relationship). He notes, "The analyst's responsibility is to preserve and model the dual state of awareness required of the patient" (pp. 400–401).12 Swartz8 asserts that the analyst's "intensification of efforts directed toward establishing the therapeutic split in the [patient's] ego so that the patient can have some perspective on his feelings and other demands is crucial as a basic therapeutic stance" (p. 315).
Although Freud1 provided suggestions on techniques for handling patients with an erotized transference, he also stated that with those patients "who refuse to accept the psychical in place of the material" (p. 167) and who insist on transference gratification, the analyst must withdraw, unsuccessful. Difficulties in the development and management of transference reactions are one of the most frequent causes for patients' changing analysts. Greenson7 agrees with Freud that if transference reactions do not respond adequately to interpretations over a sufficient period of time then one should consider changing analysts, and Blitzsen states that erotization of the transference should be worked through quite early, or else one must send the patient elsewhere.6
One would question what actually constitutes a "sufficient period of time" or "quite early" in the process. Swartz8 identifies the options of a temporary interruption of the analysis or changing to an analyst of the same sex as the patient. In extreme cases, hospitalization may be considered in order to dilute the transference by helping the patient to become involved in a therapeutic setting with a number of different people.8 In contrast, Rappaport6 believes that sending the patient away, even to another analyst, only serves to add one more traumatic experience to those of childhood and will not guarantee that the patient will not again erotize the new analytic relationship. Solomon17 agrees that maintaining a steady interpretive objectivity is preferable to transferring the patient to another analyst.
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CASE REPORT |
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Mr. A. is a 45-year-old Caucasian male who began treatment with me as an inpatient during my first year of psychiatry training. He presented with a long and complicated psychiatric history. First hospitalized at the age of 22, he had since sought treatment with many different mental health providers and had been on multiple medications. He described an inability to succeed in educational goals, employment opportunities, and interpersonal relationships despite his impressive intelligence, attractive appearance, and substantial self-motivation when not decompensated. During my work with Mr. A., I concluded that he suffered from a narcissistic personality disorder with borderline features, recurrent major depression, and transient psychotic regression. He was never delusional.During the first few weeks of Mr. A.'s hospitalization, his psychotropic medications were adjusted and we began individual therapy sessions. On the basis of his positive response to these therapeutic interventions, after his discharge from the hospital I continued to see him for twice-weekly, insight-oriented, dynamic psychotherapy.
Mr. A. was born in a small town in the Midwest, the only child of a dysfunctional, alcoholic father and an angry, withdrawn mother. Mr. A. described his father as a "terrifying man, drunk and abusive." His father freely expressed his belief that Mr. A. was another man's son, and Mr. A. would witness his father explode into jealous rages against his mother, often resulting in physical violence. Mr. A. portrayed his mother as "indecisive, critical, and deceitful." She worked menial labor jobs to ensure some steady family income but became consumed with resentment toward her husband and frequently threatened to abandon the entire family. His only loving and comforting moments were when his mother would take him, as a child, to her bed the nights his father was out drinking. Otherwise, his earliest memories were of being a child "very alone in an isolated home with no playmates."
Despite the family chaos and the absence of nurturing relationships, he was an exemplary student and excelled academically. After graduating from high school he joined the military. He began dating and eventually married. Convinced that his wife was unfaithful, he suffered fits of jealous rage that resulted in the dissolution of this marriage.
The next 20 years of Mr. A.'s life were fraught with struggle. Two subsequent marriages failed, and he was unable to hold even menial labor jobs, usually because of interpersonal conflicts. He did succeed in obtaining a bachelor of science degree from an accredited university, only to matriculate into, and then withdraw from, two prominent graduate schools.
Characteristics of the patient–therapist dyad and of Mr. A.'s psychopathology warned of the potential for a difficult transference. Mr. A. was an older man and an experienced therapy patient, in treatment with a younger, inexperienced, female therapist. He exhibited prominent narcissistic and borderline features. He was greedy and demanding of my attention and was easily slighted when he observed me interacting with other patients. He expressed an ardent need to be special in my eyes and demanded to know if he was my favorite patient. Within the first 8 weeks of treatment he described a vivid dream in which I appeared "just like in real life." In the dream Mr. A. tied my husband to a chair and he and I made passionate love in my husband's presence.
By the third month of therapy Mr. A. was openly expressing his sexual desire for me. A patient experienced in therapy, he quickly declared that these erotic feelings had nothing to do with transference phenomena. He adamantly demanded to touch me, to hold my hand. My refusals resulted in angry outbursts during which he accused me of being cold and uncaring. He lamented that I would never be capable of understanding him if we did not share times together outside of my office. Mr. A. was convinced that his desire for me was unique and that even I would agree with this singular passion if only I would allow it. In journal entries he wrote, "I love you in a particular way, in a way that nobody loves you, that no one else can love you. I see you only two hours or less a week. We've already been through this, but tell me, how do you know that I couldn't care for you more than anybody else in the world? You don't. You depend on the armor of your profession to reassure yourself, to anchor yourself in the quotidian. Not being able to touch you feels like imprisonment. I have the idea that if we could go to bed for an extended period of time—a month, say—all my problems would vanish."
As I persisted in refraining from allowing physical contact and in refusing to meet him at locations other than my office, Mr. A. grew increasingly angry. He insisted, "It would all be made easier if you would overcome your preoccupation with being a therapist and be more natural." Mr. A. began to verbalize, with hostility, his distaste for therapists and his belief that the therapeutic process was not helpful to anyone. He said that he came to appointments only to enjoy my presence and to look at me. Any interpretations I made would be met by interruptions, silences, refusals ("I don't want to talk about that!") or tirades declaring how hurtful, rejecting, and degrading it was to analyze his love. Examination of past and present relationships was futile. The existence of an erotized transference was evident.
Despite his declarations regarding the futility of therapy, Mr. A. did continue in treatment with me. During the past several years there has been a significant reduction in both the intensity and the frequency of Mr. A.'s sexual demands for me and a sublimation into more realistic feelings of affection and attachment. Mr. A. has developed an increased ability to focus on the issues that originally brought him into therapy. He can explore the intense anger he feels toward his parents and the resentment he harbors about not having experienced the home stability, love, and support that would have prepared him more adequately for life. He mourns his tremendous sense of isolation and the disabilities that result from his character pathology and mental illness. He expresses fears of never succeeding in anything and of dying alone and destitute. He is more willing to examine his role in interpersonal conflicts. He accepts, with much less shame, his dependency on me and the fact that separations from me are difficult. He remains, however, unable to maintain or pursue relationships with women and has developed only two sustained male friendships.
Every several months evidence of a continued erotized transference emerges. Mr. A. will leave graphic messages on my answering machine describing explicit sexual acts with me, or he will express the belief that when he becomes successful in a lucrative career our relationship will leave the therapeutic setting. Eruption of the erotized transference currently appears limited to times of disruption in his treatment, either due to empathic failures on my part or to interruptions while I am on vacation. A solid therapeutic alliance allows us to work together to explore the meaning of his erotic feelings, and Mr. A. demonstrates the capacity to maintain an observing ego in relation to his sexual desires for me.
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DISCUSSION |
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I believe Mr. A.'s psychopathology, specifically his borderline character organization and narcissistic character traits, contributed to the erotization of the transference. His primitive character made maintenance of an observing ego and of reality testing difficult, while his narcissistic need for affirmation further supported his desire for sexual gratification from me. These patient characteristics substantiate prior documentation in the literature linking reduced ego strength, narcissistic character pathology, and a diminished capacity to tolerate frustration and delay with the development of an erotized transference.
I agree with Blum4 that an erotized transference may serve multiple defenses, a notion this case supports. In the case of Mr. A., the erotized transference, once manifest, served as a defense against and a denial of separation; as a means to avoid feelings of envy and rage; as a more acceptable expression of dependency; and as a resistance to exploring personality traits. As a child, Mr. A. never experienced a consistent, secure, loving relationship with either parent. Instead, he suffered repeated rejection by his father and threats of abandonment by his mother. His need to fully "have" me, to possess me sexually, represented a belief that a sexual relationship with me would ensure our connection and prevent separation. Mr. A. expressed significant anger toward persons of higher social status and professional stature, and he vehemently degraded their "unrealistic" views of the world and their intelligence. Erotization allowed avoidance of exploring his envy of me, an apparently well-established, aspiring professional. Moreover, Mr. A. felt ashamed to need me; erotization permitted him to express a more socially sanctioned need, a man's sexual passion for a woman, rather than a dependency that made him feel weak and needy. Finally, because we devoted many hours to dealing with his erotic feelings, we were unable to examine aspects of Mr. A.'s personality that contributed to his poor functioning in society. Mr. A. was extremely sensitive to the exposure of any perceived character defects, and the erotization functioned to thwart painful self-examination.
Countertransference reactions and technical errors most likely contributed to the development and intensity of Mr. A.'s erotized transference. The discomfort and anger that Mr. A.'s declarations of love aroused in me interfered with my ability to explore issues in a neutral, constructive manner. Initially, I felt acutely uncomfortable when faced with his declarations. I also felt angry when he constantly rejected my therapeutic skills and chose only to adore me as a sexual object. I believe that my inability to discuss Mr. A.'s sexual longings in a compassionate, accepting manner resulted in repeated injury. In addition, fear of his anger and potential violence as well as my desire to be a caring, nurturing therapist rather than a rejecting, cold one made it difficult for me to confront his erotized transference with repeated reality testing. Reflecting on our interactions, I do not believe that any subtle enactments or seductive behaviors on my part fostered his erotized transference. As I became more at ease with Mr. A.'s declarations of love and his angry outbursts, I was able to assert reality more clearly and to explore his feelings in an accepting manner. The prominence his erotic feelings played in our work subsequently diminished.
This case supports Person's14 observation that the erotized transference is more common in the dyad of an older male patient with a younger female therapist. One may assume that the inexperience of the therapist plays a major role in the difficulty of working through the erotized transference. I would add the possibility that the age of the male patient may indicate a life stage, midlife, during which there is an increased need, particularly in narcissistic individuals, for external confirmation of attractiveness and sexual vitality.
I believe my therapeutic work with Mr. A. supports the preference for maintaining the treatment relationship if possible and working through the erotized transference rather than interrupting the treatment or transferring the patient to another clinician. Mr. A. has definitely benefited from his therapy. He shows improved ego strength, mood stability, interpersonal skills, and external functioning. His progress continues despite the fact that the erotized transference is not fully resolved. The continued transference most likely does interfere with his ability to develop relationships with women. However, I believe maintaining a stable connection to me that has excluded a sexual relationship has been an important aspect of his gains.
Perhaps a factor that has contributed to the dearth of documented cases of erotized transference in the male patient–female therapist dyad has been treatment interruption, either secondary to the patient's quitting or the therapist's feeling overwhelmed and discontinuing treatment. These interrupted cases would most likely not be included in material published in the literature.
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CONCLUSION |
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The lack of documented cases of erotization in the male patient–female therapist dyad is particularly significant. The case report presented here adds to the literature a clinical example of an erotized transference in a male patient–female therapist dyad. The case further supports evidence linking the development of an erotized transference with more primitive pathology in the patient and with relative inexperience in the therapist. In addition, the case sheds light on a possible dynamic in the male patient prone to develop an erotized transference and the many defenses that the erotized transference may serve.
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Acknowledgments |
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References |
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