The expression of sexual feelings toward the therapist is a common development in psychotherapy regardless of the gender constellation of the dyad. Much of the literature on this topic has been written about female patients by male therapists, though, and some authors (1, 2) have suggested that male patients either are too inhibited to express sexual feelings to a female therapist or tend to act out such transferences by involving themselves in outside sexual relationships. In the last 20 years or so, however, a growing literature written by women clinicians has suggested otherwise (3 – 7) . In primitively organized male patients, sexualization may be deceptive since it often represents only the phenomenological surface of the transference, and female therapists need to be aware of underlying aggressive and dependency themes beneath such transferences (7, 8) . Resident-therapists beginning to learn psychotherapy may be surprised by this inextricable connection between aggression, dependency, and sexuality in such patients, as the following case presentation will illustrate.
Case Presentation
Dr. Hobday
Dr. Mellman
Dr. Gabbard
Dr. Hobday
Dr. Mellman
Dr. Gabbard
Discussion
Since, as stated above, it is true that men are generally stronger than women, the safety of the female therapist must be of paramount importance before any therapeutic issues can be considered. The threatening voicemails made Dr. Hobday feel unsafe, so she rightly took steps to make therapy possible. The therapist’s chair must be more comfortable than the patient’s chair. Hence, the presence of security in the clinic and leaving the door open a crack were ways to make Dr. Hobday comfortable and able to think. Moreover, such measures often activate the patient’s conviction to prove a therapist wrong by being perfectly behaved. As Dr. Mellman notes, it is possible that Mr. A departed from the therapy because talking about the sexual material evoked overwhelming affects that he tried to contain and gratify by giving Dr. Hobday writings instead. Had she ignored his writings, of course, she would have been colluding with his wish to keep sexual feelings out of the verbal discourse of the therapy, and it may have become even more threatening for Mr. A.
We do not know for sure why Mr. A became angry. Were these feelings directed at the therapist’s wearing of high heels because they symbolized her status as a woman who was out of reach for him? Was the lack of reciprocity humiliating and reminiscent of experiences with his mother? One of the most striking things about the transference is not its sexualized nature but its primitivity—it has a schizoid/borderline quality that was not apparent at the beginning of the treatment. It is characterized by being unrealistic, devoid of empathy for the therapist, and unwittingly self-defeating since it portrays the therapist in a demeaning way. In any case, Dr. Hobday did manage to keep him in therapy for over a year.
Finally, we can speculate that much of Mr. A’s anger that emerged may have related to his rage at his mother for killing herself. He had spent his childhood and adolescence trying to keep his mother from committing suicide, and he may have felt at some level that he had “killed” his mother by not being a good enough son and by not watching her more carefully. In any case, his childhood experience was that his mother had abandoned him. His departure from therapy could also be viewed as active mastery over passively experienced trauma. This time, he abandoned his therapist rather than waiting for her to abandon him.
We do not know if he will return to the training clinic or not. There is often a cumulative impact of a series of therapists that allows the patient to make substantial gains over time. In any case, Dr. Hobday compellingly conveyed the challenges faced when one confronts love and lust in the psychotherapeutic setting.
Footnotes
Presented in part at the Clinical Case Conference Series at the American Psychiatric Association annual meeting, Washington, DC, on May 8, 2008. Received May 9, 2008; revision received Aug. 5, 2008; accepted Aug. 5, 2008 (doi: 10.1176/appi.ajp.2008.08050479). Address correspondence and reprint requests to Dr. Gabbard, Baylor College of Medicine, 6655 Travis St., Suite 500, Houston, TX 77030; [email protected] (email).
The authors report no competing interests.
References
1.
Karme L: The analysis of the male patient by a female analyst: the problem of a negative oedipal transference. Int J Psychoanal 1979; 60:253–261
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