Sexual Transference Towards a Therapist in the Mid-phase of Short-term Psychodynamic Psychotherapy: A Case Report

Abstract

Abstract

Transference has been described as unconscious feelings that are transposed onto another significant individual (Bloom. J Am Psychoanal Assoc. 1973;21:61-76). In the strictest sense, this occurs only in therapy settings, but in a more general sense, it occurs throughout life. Transference can be negative, positive, or sexualized. If unresolved it can create a sticky transference neurosis and impediments to progress (Koo. J Psychother Pract Res. 2001;10(1):28-36). Short-term dynamic therapy, as propounded by Dr Habib Davanloo, is structured to prevent the development of a transference neurosis and addresses the transference from the very beginning, including the first session itself. Following is a case of sexual transference which was addressed in the mid-phase of short-term psychodynamic psychotherapy.

Introduction

Transference is the transfer of unconscious feelings towards significant people in one’s past on to the therapist. The physician cannot, as a rule, spare the patient this phase of the treatment. The physician must get the patient to re-experience some portion of the latter’s forgotten life, but must see to it, on the other hand, that the patient retains some degree of aloofness, which will enable him or her, in spite of everything, to recognize that what appears to be reality is in fact only a reflection of a forgotten past. If this can be successfully achieved, the patient’s sense of conviction is won, together with the therapeutic success that is dependent on it. ³

Types of Transference

In general, transference may manifest itself as positive, negative, or sexualized. In positive transference, the patient experiences enjoyable aspects of past relationships. Positive transferences are often helpful in therapy if the patient sees the therapist as wise, caring, and concerned. ⁴ Negative transference unleashes emotions that are painful or less desired. Sexualized transference is any transference in which the patient’s fantasies about the analyst contain elements that are primarily reverential, romantic, intimate, sensual, or sexual. ⁵ In 1915, Freud addressed this phenomenon in his paper, “Observation on transference love.” By discussing transference reactions with the patient, the therapist hopes to help the patient achieve insight and to find ways to manage these feelings. Positive, negative, and sexual transference can become challenging topics for discussion in therapy. The patients are encouraged to acknowledge and discuss emotional responses with the therapist.

Case Presentation

This is a case report of a young male who was referred for therapy for psychosomatic symptoms and was managed with short-term psychodynamic psychotherapy (STDP). ⁶

Mr A, a 29-year-old male was referred for therapy for chronic pain in his back and neck for over one year against the absence of any underlying medical disorder. He reported symptoms of high anxiety and depression and inability to sustain jobs or relationships. He appeared to be of above-average intelligence having completed a professional course successfully. He gave a history of either major depressive or bipolar disorder in all his first degree family members and was the only functioning male member in his family. He reported leaving his last job a few months ago following a breakdown in his last relationship with a young woman. He expressed high levels of indecisiveness, poor confidence, low self-esteem, poor body image, apathy, rumination, anger outbursts, low mood, worthlessness, and an inability to sustain relationships.

When asked for an emotional issue, he paused and looked away. He used silences, avoidance, and vagueness as defense. He looked eager to learn; but used intense generalizations when challenged towards specificity. He described painful parts of his life in an unemotional detached way. His pain fluctuated during the interview and using the triangle of conflict used by practitioners of brief dynamic therapy. The therapist showed Mr A the link between the pain and anxiety during the interview. The patient had a good observing ego and quickly made connections. We observed high levels of projective anxiety. Every such thought about what the therapist would think about him would lead to a rise of anxiety and tensing of voluntary muscles accompanied by physical pain in certain muscle groups. In the transference, he identified feeling this way with his mother and sister. He felt that they did not appreciate him as he was not considered as smart as his sister who was well liked by the mother and other family members. In order to please them, he would do what they expected of him, but was never sure if he really wanted to do it. This included a need to get their approval for almost everything related to his career and choice of partners. This led to his understanding of the triangle of persons, another important concept of brief dynamic therapy.

This had led to the following psychodynamic formulation by the therapist.

The patient was in high resistance with isolation of affect. He exhibited the defenses of compliance and passivity. He displayed detachment, avoidance, vagueness, silence, generalizations, and rationalization as defenses against emotional closeness and experiencing of emotions. In his interaction, he came across as polite, usually allowing others to take the lead in everything and though highly knowledgeable and competent, struggled with self-doubt and feelings of worthlessness. He had good self-observing capacity and good ego strength. He had anxiety symptoms involving the voluntary muscle group. The therapist formulated a pattern of relating to his mother where his need to punish himself became ego-syntonic.

The patient agreed to the format of intensive short-term dynamic therapy. Since he complained about his inability to sustain relationships leading to his current problem, the therapist decided to focus on the therapeutic alliance and working more on the relationship with the therapist as the focal point. Weekly sessions were conducted regularly for over a year. He cancelled a session and then came a week later.

Session Following the Cancelled Session

Patient: Hi (sitting in his usual place).

Therapist: Hi Mr A (waits for the patient to begin, challenging passivity).

Patient: Looks distracted and does not respond for a while. Shifts his look to therapist waiting for the therapist (passivity) to begin. Realizes that therapist expects him to talk.

Patient: I was not able to come because my boss expected me to take on extra work and I hate him for that. He came up last Friday with some extra work because he thinks I can do it (sounding angry). The guy doesn’t understand that and I have been anxious ever since and doubting if I am in the right job. Since then I have been applying to other places. I think he will be happy to let me go. I feel really angry at him (said in a mild complaining way).

Therapist: I am sorry to interrupt you, but I was wondering what was happening here in therapy that you did not come for our work together last week. I wonder if there are some feelings towards me that are coming up here as well (bringing the focus back to the therapeutic relationship and the cancelled session which is a form of resistance)?

Patient: Oh yes (eager to talk about it)! I feel angry towards you (clenching his fists and sighing).

Therapist: Hmm... (taking a passive position and clearing the way for expression of emotions and the material that may come up with heightened affect).

Patient: I feel you may judge me if I tell you something about what happened after the last session (sighing).

Therapist: (nodding...allowing the patient to make a choice based on his understanding of the therapeutic relationship).

Patient: I know you won’t judge me; otherwise, I would not have come so far with you (self-reflection).

Therapist: So how do you feel for having walked so far with me (enhancing the positive transference and reminding him of his capacity to sustain relationships).

Patient: Very happy (sighing). I can see I came a long way (smiling). I feel completely relaxed and I want to tell you what is bothering me (expressing his wish to work further).

Therapist: Sure.

Patient: After the last session I went out with friends. There were a few of them I know for a long time. We were all dancing and I was holding a girls hand. Then, I urged to be intimate with her. I also realized that I have had this feeling to be intimate with many. This is creating doubts in my head about what kind of a person I am.

Therapist: So, you are judging yourself for having a sexual attraction towards her.

Patient: Yes, and I am feeling very guilty and since then I am experiencing pain in my neck and back.

Therapist: I notice that you avoid looking at me and are in great pain even as you sit here in the room with me (shift focus on relationship with the therapist to work through resistance).

Patient: I know, I feel you will catch me looking at your upper body. I feel you will think I am staring at you (projection). Looks away.

Therapist: (without sounding judgmental) Are these the thoughts and feelings you have been experiencing towards me?

Patient: Yes, as you sit there you remind me of the time my mother took me to a sauna for women along with her and all those women were undressed while I waited. I was so ashamed and did not know where to look (cringes in physical pain in his upper body and covers it with his hands and begins to cry in pain).

Therapist: (softly) That must have been so painful for you. I wonder what you feel towards your mother!

Patient: So much anger. I feel like hurting her. I feel like hitting her on her upper body.

Therapist: You notice that as you say that you experience pain in your own upper body as though for some reason your body should be punished for having these angry feelings and thoughts towards her. Could this be a pattern to be punished for having strong feelings towards your mother who you love as well?

Patient: It is so confusing. So many feelings towards the same person.

Therapist: Your reaction?

Patient: Relief. I know I have been struggling with so many different feelings. It’s a relief to talk about them to someone openly.

Discussion

The Position in Which the Therapist Is in the Transference Relationship

The handling of the transference relationship in ISTDP differs significantly from the handling of the transference relationship in traditional psychoanalysis. In ISTDP, the analyst moves to establish an active dialogue and an equal partnership with the patient. The transference may be positive, negative, or sexualized. Though positive transference is helpful in therapy, the negative and sexual transference if left unresolved and unexplored can cause impediments to progress with the possibility of leading to a transference neurosis. The earlier classical psychoanalytic method would allow the build-up of the transference neurosis and then the therapist would explore it with the client. Davanloo, who started video-recording sessions with his patients and developed a shortened form of psychoanalysis called intensive ISTDP, departed from Freud radically in the technical terms of how to best undo the unconscious mechanisms responsible for the neurosis. He discovered that by actively working on the resistance and bringing the latent transference reactions continuously into the open, the patient would be able to experience his or her unconscious pathogenic affects and ideas in a clear and direct way, which immediately resolves the distorted ways in which he or she had perceived the therapist. In ISTDP, the development of a transference neurosis is actively avoided. ⁷

Countertransference

When transference phenomena occur in the therapist during psychotherapy it is called countertransference. ⁸ Therapists are not immune to experiencing transference reaction. In the discussed case, the therapist initially noticed high levels of anxiety with tightening of the chest and dryness of the throat. The anxiety was related to talking of intimate issues with the patient. She recognized her fear of being judged, which stemmed from her personal experience with significant people in her own past and growing in a family where expressions of love were non-existent. As the therapy progressed, the therapist experienced very warm loving feelings towards the patient. It enhanced her ability to trust herself with the hence unexplored emotions within herself. The therapist experienced higher motivation and trust in the therapeutic alliance to move fearlessly towards resolution of the symptoms. However, countertransference can be extremely challenging and training and supervision to deal with countertransference go a long way to enhance the opening of personal challenges in the therapist which may be creating obstacles in his or her work. These challenges are enhanced in the therapist who may have little training in these issues and virtually no experience with the phenomenon of sexual transference.

Conclusion

If the therapist experiences sexual feelings for a patient, the therapist may become either inappropriately involved with the patient or aloof toward the patient in an effort to maintain emotional distance. ² Either of these responses can cause further injury to the patient. A newly trained therapist who is unable to pick up the transference and the countertransference phenomena in a therapeutic setting may not be able to look at these with the minute introspective lens with the required aloofness, causing damage to the relationship. A professional therapy training which can adequately address the importance of the phenomena is likely to reduce the risk of boundary violations in a therapeutic setting.