Modern Psychoanalysis

Meets Andre Green:

The Case of Z
JANE SNYDER

This paper presents Andre Green s responses to the author's presenta-

tion^ of a case the author had been treating for 14 years. A thorough
account of the author's work with this patient and a synopsis of Green s
thoughts and insights regarding the case are presented, and important
differences and similarities between Green s classical approach and the
modern psychoanalytic approach to the case are examined. In contrast-
ing these approaches, the author raises key questions regarding how
modern psychoanalysts work with patients.

I n December 2004, I had the challenging experience of presenting a

case to Andre Green. It was a case I had presented several times in
the past, including a presentation at a conference with Joyce
McDougall (see Gutowski, 2000). Z is a self-described male-to-female
"preoperative transsexual," whom I had been treating for 14 years at
varying frequencies, but never more than once a week. What ensued
at the 2004 presentation was a confrontation of sorts between modern
psychoanalysis and classical analysis as represented by Green and a
lively discussion of the differences. The discussion led me to think

'This colloquium was held on December 9, 2004 as part of the "Freud and Modern
Psychoanalysis" conference hosted by the Center for Modem Psychoanalytic Studies in New York
City.

2006 CUPSIModern Psychoanalysis, Vol. 31, No. 1

25
26 D J A N E S N r D ER

further about my case and the differences between modern and clas-
sical psychoanalytic technique.

The Case

Z is an individual whom modern psychoanalysts would describe as a

preoedipal, narcissistic patient. Z came in because he ostensibly needed
to be in therapy to qualify for a sex-change operation, and no other
place would take him. He insisted that gender was not the issuehe
wanted help with various aspects of being female including relation-
ships and reproduction. He also expressed a sense of hopelessness
about actual gender change, informing me that even if he had the sur-
gery he would still be "XY" and that post-surgery transsexuals had a
high rate of suicide. In the early phase of treatment, Z expressed sui-
cidality and hopelessness; he was a "freak," isolated, not accepted by
the world as female, without friends and family. He couldn't make it
as a male or a female. Z was often quite hostile in the sessions, dep-
recating toward me, provocative in his remarks, dismissive of my
appearance and my competence. After several months he revealed
something he really wanted help with, his "action-compulsion" to go
out and exhibit himself in women's underwear, an act that both pro-
vided tension relief and led to self-loathing. He also feared being
caught and revealed that he actually had been caught in the past. He
had fantasies of being humiliated by the policeman or woman who
caught him. He worried about being locked up in prisonwould it be
a male prison, in which case he would surely be raped, or a female
prison, in which case he would have to wear a chastity belt and then
would become a sex toy.
This seemed to be Z's dilemmaneither gender identity was satisfy-
ing: if male he would be raped and then would kill himself", if female he
would be castrated and unable to achieve sexual discharge (the prefer-
able alternative). While expressing a desperate wish to be controlled in
this behavior (be locked up at night, for example), in the sessions he also
provoked me to control him (order him to lie on the couch or to remain in
his seat), while insisting I couldn't control him (he asked for a list of
behaviors, a prescription of do's and don'ts, but wouldn't promise to fol-
low them). When I went on vacation, he was hospitalizedsometimes
voluntarily; sometimes he provoked a hospitalization (for example,
appearing at his psychiatrist's office announcing he had just swallowed a
 Modern Psychoanalysis Meets Andre Green: The Case ofZ D 27

bottle of pills with vodka). After a year and a half of desperation about his
inability to control himself, I made an emotional communication, asking
him if he needed to be with me 24 hours a day. This led to much discus-
sion. For nine months, we reviewed the pros and cons of living with me:
How would I control him? Could I? Did I live with others? Would I be
having sex? Where would he sleep? What would happen to the analysis?
Eventually Z decided it wouldn't work, and he would live "across the
street." He also noticed I had a wedding ring; did it mean I liked penises?
We began to discuss the merits of being a woman with a penis. Z alleged
he was a lesbian; he had only ever had "sex for one" (masturbation); he
couldn't imagine sex. Heterosexual sex disgusted him. For him sex was
lying on another's stomach (reminiscent of infant-mother body contact).
Males were violent rapists. Females had more feelings but were vulnera-
ble to rape. It was penetrate or be penetrated, both violent acts.
My countertransference feelings were intense in working with Z. In
the beginning I was frightened of him, of his palpable rage and high
tension states, his tendency to actionjumping off the couch, rolling
over, coming close to show me his electrolysis results, commenting on
my leg, acting very intrusive. On one occasion, Z pulled a knife out of
his pockethe was carrying it to protect himself In other sessions he
pulled a large submarine sandwich or licorice sticks or a videotape of
"Women Unchained" from his pocketbook. In response to his provoca-
tions, I felt an urge to make a sadistic remark or to tie him to the couch
on which he was perpetually moving about. At times I felt repulsed by
Z, at other times sympatheticwhen, for example, he informed me I
was his only relationship, one hour a week. I also consistently felt
trapped in this charadewe both knew he wasn't a female, yet he
expected acceptance from me while I constantly felt his maleness, his
phallic intrusiveness. I felt imprisoned. This seemed to mirror his own
sense of gender as a prison, the female gender being a prison he needed
to keep his impulses in check. Z was openly envious of my femininity;
I felt he wanted to invade me, to steal it for his own.
In my conceptualization, Z was dealing with inordinate amounts of
self-loathing and rage and was using the feminine identity to manage
his defused drive states. The self-loathing was concentrated in his
penis, an instrument of destruction and violence. He blamed his freak-
ish appearance for his isolation and bemoaned his lack of acceptance as
a woman. In his withdrawals from the world (and from therapy at
times), he became a "slug," genderless, free from all demands, free to
do what he wanted. The female hormones he was taking reduced his sex
drive and eliminated erections; he could exist in a non-aroused state. He
took a number of breaks from therapy. In the first break he left in a rage
2S a J A N E S N YD ER

when I explored whether I should see him once a month for free to
enable him to keep coming weekly. He was outraged that I was suggest-
ing that he needed therapy, that he needed me. I represented pressure to
him; he needed to get away. I was helpless to help him; he needed more
resources, money, a job, friends. I couldn't supply these; he didn't need
therapy. When he returned at my request, coming in once a month at
first, he looked masculine and was hostile, resistant, and out-of-control
in his exhibitionism. He projected his wish to stay connected, his
dependency feelings into me: he came because of "my needs." He also
sadly described himself as a failure at being a woman and a failure at
being a man, and warned me that if I suggested he be a man, he would
kill himself. When threatened with discharge from therapy for nonpay-
ment of his fee, he returned to regular sessions, indicating he didn't
think it was helping, but he liked being with me. Over time Z has
seemed amused and more accepting of being a "woman with a penis."
He has brought me pictures of good-looking men in their underwear, of
ads for sex toys, information on sex addicts anonymous since I was
probably a sex addict too. Perhaps I placed the personal ads looking for
a submissive "maid," counterpart to a dominatrix. Perhaps I was a trans-
sexual too. The nature of the transference had shifted from a negative
narcissistic transference (I, like he, was a failure, inadequate, and help-
less) to a positive narcissistic one (I was a sex addict too).
Over the years Z has continued to torture me with threats of suicide,
of homelessness, of stopping his thyroid medication, of disappearing,
withholding information about real strides he has made in pursuing
education and training. He has also expressed anguish, loneliness, and
despair at ever being able to be accepted as a woman. He has taken
breaks when he has declared me impotent to help him. I couldn't
change the world that persisted in rejecting him as a woman or as an
adequate employee (his tendency to lose jobs insured his inability to
pay for reassignment surgery). When he returned recently after a break,
he announced he had stopped taking all medications including the
female hormones. He still had erections. And he still didn't need me.
He was coming for my sake. I remained helpless to help him as he
remained helpless in the face of the pressures of the world.

Green's Response

Andre Green asked me one question at first: What did I think about the
patient? I responded that my tendency was to say what I felt and had
 Modern Psychoanalysis Meets Andre Green: The Gase ofZ D 29

used my feelings to understand him. I then responded with my concep-

tualization, focusing on Z's symptomatology, his feminine identifica-
tion, as a way of managing his inordinate aggression and self-hate and
his exhibitionism as a way of managing his incredible tension states.
All he wanted to do was go running around in women's underwear.
Green had me repeat this sentence: "All he wanted to do was go run-
ning around in women's underwear." I explained that I had worked with
my emotional reactions, which had changed over time, and used them
to understand him, treating them as inductions. Green asked me if I
believed him when he maintained that if he could be a woman, he could
eliminate the tension states and be a "nice" person; I said no. Green
asked me why had I presented this patient? Did I really believe he
would work with such a case, and what did I expect from the therapy?
I explained that I expected he would verbalize more, act out less, ulti-
mately accept his maleness. Green asked me on what grounds I would
believe such a thing. I explained that if for him being male meant being
violent or destructive, accepting these unacceptable feelings and
impulses would mean he could accept his maleness, his penis. Green
asked me why I thought I could help him accept his masculinity, did I
think this attitude might be the result of a repression? He went on to say
he didn't see destructivity as the primary issue in the case. He saw a
defense against homosexuality. The aggression was exhibited toward
me, the analyst, in Z's derogatory attitude toward me as a woman and,
he added, Z cannot imagine a woman without a penis.
Green went on to elaborate, through the case discussion, his ideas
about analysis: who can be treated, how it is done, what is and isn't
analysis, and what it requires. Green was adamant that a once-a-week
treatment would never be enough to change anything. In the case of Z,
he saw no transference. And he didn't see Z's transgendered identity as
a neosexuality. He saw it as a delusion. Later he elaborated on what he
sees as a shared social delusion that seems to be going on about trans-
sexualism, accepting gender-reassignment surgery as an acceptable
strategy to "being born the wrong gender." He emphasized that Z is
avoiding experiencing his homosexual urges"I'm not a homosexual;
I'm a woman"and attacks me, the analyst, as a woman, provokes and
pushes. He described Z's rejection of homosexuality as "a kind of fore-
closure, to use a Lacanian term, of his homosexuality," which might
bring him to build up a delusion that serves him "as a point of reference
essential for his survival."
Green noted that Z rejects thinking, acts out, threatens acting out,
and never asks why about anything; he doesn't reflect on himself
Z doesn't want analysis. For him, the relationship is "a kind of false
30 n J A N E S N YD ER

delusion." With a case like Z, one can't interpret; he might get worse.
He comes to torture the analyst, to see the analyst as impotent, to avoid
change. There is no desire to understand himself, to know himself. Z
evacuates his past. It is true he has survivedhe needs to keep his penis
to survive. He is avoiding psychosis. He is not a "true" transsexual; he
wants his penis and his male identity (I certainly experienced this in the
countertransference). Green acknowledged that I had pointed out Z's
fear of intrusion, invasion, but interpreted this as his fear of a penetrat-
ing mother, not the fear of himself as rapist. He asked if it was possible
to get to the fear of his homosexuality, noting Z is not neurotic, but he
is fearful of becoming a woman as a homosexual. He exhibits himself
as a woman, but not the feminine desires. When he goes out, what is his
sex life? What is the fantasy? He pronounced that Z is a patient who has
no mental functioning. He doesn't want to understand anything about
himself. As such, he is not an analytic patient and not a patient with
whom Green would work though he wouldn't rule out others' working
with him. However, Green noted, it is interesting that Z stopped the
medication. This, Green said, is the real question: why did he stop act-
ing out on his own?
To this. Meadow responded that modern psychoanalysts have an
answer: "We join them for so long on this superficial level, never
attacking their defenses. Sooner or later it is our hope that they will
attack their defenses." Green's response was "You are optimistic." In
the evening's discussion a number of differences were highlighted
between modern psychoanalysis and traditional analysis as represented
by Green.

What is Analysis and Who Can Be Treated?

Green insisted that Z is not an analytic case for two reasons. First, the
treatment is weekly at best. Green made clear he does not consider a
weekly treatment analysis; it is just "holding the patient's head above
water." The second reason was that Z "has no mental functioning." He
does not reflect on himself, i.e., he doesn't want to know about him-
self Furthermore, interpreting the underlying homosexuality could be
dangerous.
By contrast, modern analysts often work with patients once a week.
We put patients on the couch, we work with the transference, usually a
narcissistic transference in the beginning, and we consider this analysis
 Modern Psychoanalysis Meets Andre Green: The Case ofZ a 31

or, depending on the case, pre-analytic work. Spotnitz (2004) explains

the frequency should be one of "optimal intensity," recommending
once a week in the early stage of treatment when the patient primarily
wants relief; the frequency should be such that the patient is "mildly
'hungry' to resume his communications to the analyst" (p. 6). Meadow
(2003) specifies a broader range of possible frequencies depending on
what the patient can tolerate (once a week to daily).
Green's major criterion for undertaking analysis, however, was that
the patient demonstrate "mental functioning." Green elaborated on his
concept of mental functioning: "The way he associates, the way he
reports a dream or not, the way he brings the relationship that he tells
about into the therapy. The patient says something, opens up a question,
and the analyst, who may choose to remain silent for a very long time,
says something, and you know if he is able to work or not by his
response. And his response is not, 'Oh, I know what happened to me.
When I was three years old, I saw my mother naked.' This is not psy-
choanalysis. This gives me the feeling what I can do and what I can't
because I can't impose anything. It is the patient who tells us what we
can do with him or her. If patients reject, say 'No, no, this is impossi-
ble, this will drive me mad, drive me crazy,' you respect. . . . He [Z]
doesn't reveal anything about what he thinks, about how he feels, where
it comes from, not a word on the father. I see no mental functioning in
this patient."
When asked how mental functioning develops. Green said, "Mental
functioning develops in the analytic interchange, and as I told you, by
the simplest example, 'Ah, what you say makes me think of. . .' and the
patient says something very different from what you said, but you
understand there is a connection between his answer and your question.
You can infer what is the mental function that makes [the connection].
. . . Association, association is the great thing on which you
rely. . . . Association is imagination. Imagination is the possibility to let
the unconscious speak."
Green was asked about the preverbal patient and mentalization and
responded: "You can have a preverbal function just the same. The pre-
verbal function is the way the patient associates. It is not necessarily
something which says 'reminds me of.' 'It makes me think' is the sim-
plest form. You can see certain changes in the patient's voice; you can
see it creates a kind of agitation; something is going on. It has not been
able to be conveyed by words; it is some kind of agitation. Or the
patient may say, 'You know, but what you said makes me anxious,' and
then comes back to the analyst, who has to ask himself why did this
make the analysand anxious. Analysis is not something which you can
32 O J A N E S N YD ER

predict: I'm going to say that, and this is going to happen. You are
always surprised by what happens, and you ask yourself why did this
happen this way or this other away. There must be an axis of work; the
axis of work is the indication for psychoanalysis. It's not the sickness
of the patient; it's not the regression of the patient; it is the curiosity of
the patient about himself, what happens to himself . . . We're not inter-
ested in behavior; we're interested in the mind and how the mind func-
tions in that specific situation when it is in contact with another mind.
This has nothing to do with intersubjectivity."

Modern Psychoanalysis and the Unmentalizing Patient

As modern psychoanalysts, we are willing to work with unmentalizing

patients who don't seem to be interested in getting to know themselves.
They come in order to alleviate pain and suffering, to inflict it on the
other/analyst, to be listened to and accepted, to have their distorted
ideas validated, to "keep their heads above water," as Green puts it, to
survive. They are not looking for psychic change or to know them-
selves; they are looking for relief. They are not even necessarily seek-
ing an analyst; they are seeking a relief agent. Their conflicts may be
enacted or expressed somatically, not verbalized. As Meadow said dur-
ing the discussion: "We work with whoever we feel we can work with."
Spotnitz (2004) notes.

When the pathologically narcissistic individual enters treatment, his

capacity to work analytically is assumed to be extremely limited.
Consciously and unconsciously, he reacts negatively to requirements that
force him to feel his own helplessness and inadequacies. Primitive ideas
and explosive emotions that are difficult to verbalize dominate his erratic
behavior, (p. 94)

Modern analysts are willing to work for a long time with such
patients until they begin to mentalize, i.e., to think about or question
their patterns of behavior, and show some readiness to undertake ana-
lytic work. We study their tension states and patterns of discharge. We
understand their actions and enactments as symbolic communications.
We don't interpret unless the patient shows an interest in understanding
something. We use other techniques to foster the development of a nar-
cissistic transference, in which the analyst is experienced as part of the
 Modern Psychoanalysis Meets Andre Green: The Case ofZ D 33

self or as a mirror or twin image or as nonexistent. The negative narcis-

sistic transference is dealt with first.
My patient engages in continuous action and projective identifica-
tion and very little mentalization. I agree with Green's formulation: Z
by and large has not shown an interest in reflecting on himself, in self-
understanding, in analysisthough he has occasionally reported a
dream or a fantasy. Consciously Z wants me to accept his recreated
feminine self, to support his acknowledged-to-be-phony feminine iden-
tification. Meanwhile, he discharges his aggression toward me with
provocative jokes and comments; he is intrusive in his behavior, declar-
ing me inadequate, impotent to help him. While claiming to be a
woman, he has consistently evoked in me the feeling that he is a man,
a man carrying out a pretense of being a woman. He presents a desper-
ate need for me to go along with this charade, threatening suicide if
forced to be a man. He has sought my control over his action-compul-
sion and rejected it, sometimes referring to it scornfully as the "rein of
Jane." He taunts me, has threatened me with suicide, and urged me to
lock him up. I have not questioned his self-presentation; rather I have
reflected his questions and joined his perceptions, making occasional
emotional communications (e.g.. Do you need to be with me 24 hours
a day? What's wrong with being a woman with a penis? Is there any
neighborhood where you wouldn't be a freak? If you are going to
attempt suicide, you need to see someone elseI am not helping you).
Z engages in unmentalized action to disavow his impulses, sexual
and aggressive, and to defend against the possibility of unwanted
thoughts and feelings. As Green says, he evacuates his past and negates
thinking. He lives in the present, continually creating himself and look-
ing for mirroring in a world that is continually failing him. When he has
reflected on himself, it has been painful: he is a failure as either gender,
he is a freak, he is alone, he might as well die. Then the whole action
cycle starts over again. As his analyst, I have studied his communica-
tions and enactments in the transference as well as my countertransfer-
ence responses in order to understand what is disavowed. In writing on
treatment of borderline states. Green (1975) has described the kinds of
defenses employed by Z: acting out as expulsion of psychic reality,
splitting, and decathexisthe latter two representing a fundamental
dilemma between delusion and death.
In this process of continual enactment and projective identification,
the treatment-destructive resistance is part of the enactment of
the patient's basic conflict and urge to leave parts of the self with the
therapist as well an enactment of the urge to destroy the treatment and
the therapist (the feminine identity). Modern analysts work to keep
34 n J A N E S N Y D E R

treatment-destructive patients in treatment, calling them, inviting them

back for a session. Green criticized this calling back as an acting out of
the analyst's "fascination" with the patient and advised letting the
patient go, particularly in a case like this where he saw little chance of
analysis really taking place. In my view, my patient's repeated cycle of
leaving the analysis and returning, with the mixed-gender presentations
and accompanying feeling states, has been valuable in the treatment
and constitutes a symbolic enactment of leaving a gendered, pressured
state to go into a non-aroused ("slug") state. He becomes treatment
destructive when masculinized and angry and withdraws into a slug
state, then returns for regular sessions, feminized again, feigning indif-
ference to the analyst. As Meadow (2003) has explained, the analyst
may have to carry the motivation for life and for connection, particu-
larly in the early phase of treatment, and work to rouse desire in the nar-
cissistic patient.

Induced Feelings and Mental Functioning

Green stresses that mental fiinctioning is a requirement for analysis to

take place because it creates the ability to associate, to reflect and imag-
ine, and to be curious about oneself. He indicates there must be "an axis
of work," which may occur with preoedipal as well as oedipal patients.
He indicates that with the preoedipal patient, the nature of the associa-
tion may be different, not a new thought but a feeling of anxiety, a non-
verbal indicator of agitation.
Many current analysts write about the importance of working with
countertransference feelings in an effort to understand early feeling
states; e.g., Chasseguet-Smirgel, 1984; Ogden, 1995, 1996; Joseph,
1985; Spotnitz, 2004. Green (1975) himself discusses the nature of
work with the borderline patient as inductive, "hence its hazardous
nature" (p. 6). However, as modern analysts, we do not usually interpret
our understanding to the patient until the patient has become an analytic
patient and asks for interpretations. Meadow (2003) explains that the
analyst will "get to know a patient by how he himself thinks and, more
important, feels about the patient he is with . . . but the patient induces
feeling states in the analyst that tell more about his emotional conflicts
than do his stated opinions" (p. 6). The narcissistic patient is unable to
verbalize his affective states, to mentalize. The analyst relies on
induced feelings to understand the case. The induced feelings may be
 Modern Psychoanalysis Meets Andre Green: The Case ofZ D 35

the patient's own unmentalized feeling states or feeling states experi-

enced by the patient's early objects. Just as Green points out, the ana-
lyst must analyze her own feelings in order to make use of them
because they may be "in collusion with the patient."
My patient, as noted, induced a number of^ strong feelings in me. The
first was intense anxiety, which I understood to be his experience as
well, but which I also experienced as fear of penetration, i.e., rape. He
later voiced this fear when he told me that "therapist" can be syllabi-
fied as "the-rapist" and when he reported an incident of what felt like
anal rape at the hands of a gynecologist. This induced feeling surely
supports Green's formulation of repressed homosexuality (although
disavowed homosexuality may be a more accurate description). I also,
as reported, felt very trapped by this patient, a feeling I experienced in
a number of ways: trapped into responding to him as if he were a
female, which we both knew was a lie; trapped by his sadism, an
unwilling partner to his constant provocative jabs; and trapped in a gen-
dered body whose very existence seemed to overstimulate my patient.
I found myself wondering if he had ever murdered anyone. His rage
was so visceral, I felt inadequate to contain it; the female identity as a
container for aggression was not working. As time went on I experi-
enced other feelings, including sadistic feelings and a strong urge to
control Z, tie him to the couch if necessary to keep him in place. I also
felt at times he wanted to crawl inside me. He was intrusive, a penetrat-
ing presence although he himself seemed impenetrable, ignoring my
questions and comments. I also worried about Z as he threatened sui-
cide, homelessness, taking off without a trace.
As Z over time got his action-compulsion under control, he became
a more "ordinary" patient, continuing to long for an intimate relation-
ship, continuing to identify himself as a woman, but joking with me
about being a woman with a penis. Z projected his desire for connec-
tion into me, declaring I wanted him to go out and meet other women
and become more "feminine," but that I wanted him to keep his penis,
which he continued to allege he despised. The tension level in the room
lessened; I felt less anxious; he seemed less rageful. We entered a sta-
tus quo where we had positive feelings of acceptance and even affec-
tion for each other. Z brought me gifts that reflected the importance of
the relationship to himdatebooks with his appointment time written
in, a mother's day gift, science fiction stories about aliens he thought I
would enjoy.
A number of analysts have written about countertransference experi-
ences with perverse and, more specifically, with transsexual patients.
Oppenheimer (1991) describes the experience of "the imprisonment of
36 D J A N E S N YD ER

the other in a double bind" when working with the transsexual patient
who "limits the analytic action . . . dictating to the other/analyst what
he is to confirm" (p. 229). Stein (2005) discusses the attempt of the per-
verse patient to make a "perverse pact" with the analyst. In discussing
a case, she notes that "[t]he script that played us was that of one person
treating the other as a puppet... a terrible caricature of an analysis" (p.
785). Later she concludes that "[t]he perverse solution . . . lies in strik-
ing a pact in which two invalids invalidate the outside world, creating
their own rules, in order to validate and vindicate their mutual weak-
ness and indulgence" (p. 792). This is what Z has sought to do with me.
As Parsons (2000) puts it, the object is depersonalized and merged with
at the same time. This description of being depersonalized and merged
with at the same time captures my early experience with Z. Later, the
need for an accepting mirror to reflect his professional feminine status,
being "two girls together," took over, but it broke down whenever this
status was questioned in the world. At that point I became useless and
helpless, an inadequate container, as he became enraged, masculinized,
and rejecting of femininity and dependency. As noted, he recently
returned after one of these cycles, announcing he still had erections.

Case Formulation: Sexuality versus Aggression

Green's formulation of my patient's basic conflict as a foreclosure, or

repression, of homosexuality made me rethink my own formulation of
Z in light of the case material. In support of this idea, I have consis-
tently experienced him as male, phallic, and contemptuous of women,
an unconvincing female. While alleging disgust toward his penis and a
desire to eliminate it, Z has also masturbated as part of his exhibition-
istic ritual and has noted that he has made no "irreversible changes."
His quandary, early in the treatment, about which prison would contain
him indicated a fear of homosexual rape. He has fantasized about "get-
ting it up the ass" (with a tampon) since he lacks a vagina. He has also
sarcastically joked about growing a beard or becoming a gay hair-
dresser when his current, more feminine career choice has been in jeop-
ardy. He has brought in pictures of good-looking men for me "since I
like males." However, as noted, he has insisted that he can't make it as
a male and would commit suicide if "forced," implying that I could
force him. Z has projected into me the authority to lay down rules (ask-
ing for lists of dos and don Vs to control his behavior) and to enforce
 Modern Psychoanalysis Meets Andre Green: The Case ofZ n 37

them/control him at the same time, taunting me or at times despairing

of my inability to control him. He has sought my "rein" and defied it.
For example, we continue to spar over his use of the couch. He usually
sits first, gives me gifls of news articles he thinks I would like or ads
for things I may need, and begins to talk, only lying down reluctantly
when I ask him to. "Being forced" is a major element of the transfer-
ence-countertransference dynamic.
Green noted that Z tells me nothing of his fantasy life, and I reported
very little in the presentation. However, Z has told me some fantasies.
He experiences excitement at the idea of being humiliated while wear-
ing women's underwear or a maid's costume, being a "slave" in a dom-
inatrix-type relationship, or being a sex toy for women while wearing a
chastity belt. He has fantasized being a prostitute. He reports being
attracted to women, has been flirtatious and seductive with me, but his
idea of sex is lying on a woman's stomach. Heterosexual sex disgusts
him. He has "sex for one" (masturbation), which disgusts him as well
since he has to use his penis. He also reported being attracted against
his will to a transsexual female he heard perform and has reported
dreams in which gender and murder play a prominent role. In one
dream, he is lying on a bed naked, a towel over his genitals; I am seated
at a desk in my underwear. A man comes in, possibly my husband, and
shoots him. This dream supports the idea of a disavowed homosexual
wish. In another dream, Z is crawling through a tunnel and comes to a
fence. A woman is lying there dead, blood in her "Madonna-like" hair.
Unable to speak Z points to her to show her to someone. A birth dream
in which the mother is dead and Z is impotent (speechless), this dream
indicates earlier, preoedipal issues, issues of life and death.
Green's formulation of a disavowal of homosexuality makes sense at
one level, but is it the bottom line? My patient precludes male homo-
sexuality by identifying himself as a woman and declaring himself a
lesbian (an inverse homosexuality, he is a homosexual woman), by stay-
ing away from men, by declaring he wants to cut off his penis, by
exhibiting himself as a woman. In the transference, however, he is often
provocative, intrusive, hostile, sadistic, and at times playfully resistant
and noncompliant; at other times he is despairing of his ability to be
accepted and, at times of greatest femininity, manic. A conflict about
penetration is enacted: he fears rape and penetration while enacting a
penetrating demeanor toward me. He repeatedly seeks to destroy the
treatment and render me powerless. When he leaves the session, he is
enraged and appears more masculine. He goes off hormones and
becomes masculinized, more potent himself. I infer he is engaged in an
enactment: with me he needs to be a woman, as feminized as possible.
3S a J A N E S N YD ER

but intrusive, a phallic woman mirrored by another phallic woman. He

provokes my "rein," my rules and limits, or enlists me as a mirror of a
professional woman. Any indication of dependency leads to his leaving
in a rage and becoming masculinized and then, usually sluglike, focused
on survival. He acts to preserve his penis, ensuring he never has enough
money for surgery, continuing to masturbate. In the transference-
countertransference matrix we are dealing with threats of and defense
against penetration, provoking control and defying it, seeking mirror-
ing for a false identity alternating with helplessness and despair, which
he seeks to leave with me. On the intrapsychic level, Z acts out a con-
flict between parts of himself: his impulses are aroused to intolerable
levels, and he seeks and rejects control from me, representing the con-
trolling part of himself He provokes me to set limits, contain him, "tie
him down" while indicating he will do whatever he wants. He leaves
me at times with his own intolerable tension states, going off to relieve
himself of "pressure" and maintain a non-aroused state, a state only
possible in isolation. My genderedness is overly stimulating to him. He
envies and wants it, giving me the feeling he wants to crawl inside me
and take over my body, but at the same time he rejects my body as inad-
equate, despicable. In fact, the feminine identity cannot contain his
arousal states, particularly when he is enraged.
As Freud (1927, 1938) and subsequent analysts (Bak, 1968;
Greenacre, 1968; Chiland, 2000; McDougall, 1991; Parsons, 2000)
have emphasized, disavowal through action is the main defense in per-
version. Similar in function to delusion, disavowal enables an alternate
reality to be maintained: reality is acknowledged and denied at the
same time; two contradictory ideas are both experienced as "real," e.g.,
women have no penises, and there is no difference between the sexes,
no castration. The perversion disavows the difference between the sexes
and the generations.
Fenichel (1945) in his chapter on perversions considers the dynam-
ics of femininity in men in his discussion of homosexuality. He notes a
variety of dynamics, and the possibility of object choice being either
male (i.e., homosexual) or female (i.e., the maternal object or a girl
among girls). In all cases, the identification is with the mother, and
there is an intense fear of castration. He notes that men with "an intense
aggressiveness" may identify as a woman so they can ward off the
aggressiveness, and the unconscious thought is: "If I were a woman, I
would have the opportunity to take revenge on men" (p. 336).
Many analysts writing on perversion discuss its fianction in binding
extreme aggression. Stoller (1975) calls perversion "the erotic form of
hatred." In perversion, not only are genital/gender differences dis-
 Modern Psychoanalysis Meets Andre Green: The Case ofZ D 39

avowed, the "urge to destroy" is also disavowed; aggression is erotized.

Perversions represent a defusion of the drives or a "pathological fusion"
of the libidinal/erotic drive fiinctioning in the service of the aggressive
drive (Kernberg, 1992; Rosenfeld, 1971). McDougall (1991) discusses
the role of the perverse act in the psychic economy and the necessity of
repeating it over and over to "emphasize" the predominance of overly
destructive erotic aims as a way of dealing with "unfathomable rage."
The compulsive neosexual act masters or "renders innocuous" danger-
ous parts of the self (McDougall, 1991, 1995). In some cases the
unfathomable rage may be traced to early experiences of sexual over-
stimulation or the mother's use of the child for her own narcissistic
needs. Lacanians talk about perversion as stemming from the mother's
unconscious use of the child as her phallus, unsymbolized and unsym-
bolizable because the "father's law," separating the child from maternal
desire, has been incompletely enacted (Fink, 1997). In Lacanian terms,
the mother's lack (of a phallus) is never named, and the child becomes
the unconscious object of desire, her phallus, sacrificing himself to the
engulfing mother. According to this view, an unconscious goal of per-
verse behavior is an attempt to coerce the other into declaring the "law,"
i.e., the incompletely articulated law of the father, in order to free the
individual from subjugation to the mother's unnamed desire.
Oppenheimer (1991), a self psychologist who has treated a number
of transsexuals, discusses the roots of the disorder in the earliest states
of ego formation, pre-representation, when disintegration and fragmen-
tation are a real danger. The false identity is "a compensatory self struc-
ture" created to split off hated parts of the self, located in the penis.
What cannot be contained in the self structure, in drive theory terms, is
the enormous quantity of aggression. Other analysts also describe the
function of perversion as a defense against psychotic anxiety or disin-
tegration into psychosis (Stein, 2005; McDougall, 1991).
Are these two viewpoints regarding Z's dynamics incompatible?
Disavowed homosexuality is a more Oedipal construction. As Green
notes, Z becomes a woman rather than behaving as a woman in the sex-
ual act. The defense may be erected against penetration by the phallic
mother rather than by a male (father), but the identification is with the
phallic mother. Z has moved over time in the analysis to acceptance of
being a woman with a penis and enjoyment of^ my liking penises.
However, the sadism in the transference and countertransference and
the enactment in the treatment-destructive phases indicate that aggres-
sion is also a major factor in his dynamics. Z's acting out a female iden-
tity and his exhibitionistic behaviors function to disavow both homo-
sexuality and his enormous aggression, all the more dangerous as it is
40 D J A N E S N YD ER

tied up with penetration fantasies. Green contended that Z is more

frightened of being penetrated than of penetrating. While acting in a
penetrating manner, Z is often impenetrable to any questions or com-
ments from me. He flaunts being a woman while bemoaning his victim
status and denigrates femininity at the same time.

Negative Therapeutic Reaction

During the discussion with Green, Meadow brought up the issue of the
negative therapeutic reaction and the refusal to associate, which Green
amplified to include the destruction of associations and interpretations.
He noted, "I may also expect for this to last for years. And one day, you
don't know why, the patient seems to pay attention to one thing you say,
and it is not new, you have already said it in the past, but he wouldn't
consider it. And one day the patient says, 'Well. .. maybe.'"
Kernberg (1992) and others (Joseph, 1982; Stein, 2005) have noted
the inevitability of the negative therapeutic reaction with the perverse
patient, the attempt to derail the analysis to pursue perverse aims, to
seduce or coerce the analyst into the perverse script (what Stein has so
eloquently described as "the perverse pact"). Richards (2003) notes the
induction of helplessness in perversion and the focus on sadomasochis-
tic aims.
Although Z has seemed quite dependent on the analyst and the ther-
apy, while declaring its uselessness, he has resisted being in analysis,
that is, examining himself and his life. He exists in the present only,
discusses how things are going, always evaluating whether he is being
accepted as a woman and expressing resentment toward those who
don't treat him respectfully. I am someone he checks in with about
his life, exhibiting himself as a woman to me, seeking a kind of mir-
roring. While interested in alleviating suffering and getting his action-
compulsion under control, he has had a strong need to resist the ther-
apist as the controlling, phallic mother as well as to live "under her
couch" (i.e., skirt). He provokes the other and perceives the other as
demand. He engages in continual enactment, enlisting the other in a
dictated function and, as Green suggests, rejecting thinking. Z does
not want change; he wants relief, a status quo in which he will feel
no disturbing impulses, no pressure to do anything. If I reflect back
to him an acceptance of his female status (that is, if I don't question
it), he is relieved but continues to be provocative, "jabbing" me and
 Modern Psychoanalysis Meets Andre Green: The Case ofZ a 41

ignoring any comments I make. If I do question (e.g., I asked him

what he was doing in the ladies room where I'd run into him the pre-
vious week), he becomes truculent, then expresses despair and hope-
lessness. It does seem to be a matter of delusion or death: either a
false identity, a false intimacy, or an uneasy equilibrium until the cycle
of treatment destructivenesskilling off the analyst and the analysis
as well as all need and connectionbegins again. Rosenfeld (1971)
describes a similar dynamic in severe narcissists, who prefer to "assert
their superiority over the analyst... in being able to control and with-
hold those parts of themselves which want to depend on the analyst
or a helpful person. They behave as if the loss of any love object
including the analyst would leave them cold and even stimulate a feel-
ing of triumph" (p. 173). In a later article, Rosenfeld (1975) writes
that narcissistic omnipotence is a defense against destructive aggres-
sion toward the envied, potentially gratifying object.

What Leads to Mentalization?

The question of what leads to mentalization was not answered in the

discussion with Green. Meadow said at the time that years of joining
lead to the patient's eventually attacking his own defenses, giving up
the narcissistic defense, and becoming an analytic patient. The analyst
functions to reflect and mirror the patient's communications and con-
tain and accept his projections, joining his perceptions until he is ready
to give them up or begin to question them. In modern psychoanalytic
literature (Spotnitz, 2004) there is the understanding, supported by case
examples (e.g.. Poser, 2002), that utilizing joining and reflecting tech-
niques, providing ego insulation, and occasionally making emotional
communications based on induced feelings will enable the patient to
work through the narcissistic transference, develop an object field in
his mindseparate from the ego field and growing out of fused ego-
object impressionsand ultimately develop an object transference, that
is, an awareness of the analyst as a separate person. This process entails
the use of the analyst as a part of the self or a projection screen, con-
taining and digesting projected contents, providing communications to
the analysand that are digestible and that make being in the room
together tolerable. Green (1975) describes the analyst's experience of
"ill defined impressions . . . which seem to reproduce certain drive tra-
jectories, through the expression of internal movement in the analyst
42 D J A N E S N YD ER

giving rise to feelings of envelopment and development." With "inten-

sive work" these movements reach consciousness and are transformed
into "sequences of words." The analyst "binds the inchoate" and sym-
bolization occurs (p. 11). As Meadow (2003) describes this process, the
analyst experiences emotions and thoughts induced by the patient and
thereby, through projective identification, "exists at the core of the
patient as she relates to herself" (p. 96). The analyst becomes a twin
image to the patient and over time the patient will take back projected
parts of the self (p. 97). In the presence of an analyst willing to regress
to and mirror early levels of development, the patient will slowly
develop the capacity to reflect on the self as well as an awareness of the
other as other, as separate, with a separate mental field.

Conclusion

Green's comments led me to expand my own mentalization about my

case, and I developed new ideas about the conflict Z enacts and
defends against. However, while I have new ideas and new interpre-
tations of the case data, I have not felt a need to alter the way I work,
which is to rely on understanding my induced feelings, think about
what they mean, and use the feelings to formulate questions. New
ideas may, of course, generate new questions. Z is not yet a mental-
izing patient who reflects on himself. He has progressed from con-
stant self-destructiveness and evacuation of need to a less rageful exis-
tence and from a negative to a positive narcissistic transference. One
question that has arisen for me regarding working with a patient like
Z, one with an intractable resistance, is: as modern analysts are we in
collusion with the patient by joining him, engaging in ego-insulating
techniques, and not demanding more psychic work over a long
periodthat is, are we colluding in the status quo? How does the ana-
lyst know if it is a gratifying status quo that prevents further building
of mental structure, particularly if, as in the case of Z, periodic treat-
ment-destructive enactments break up the status quo and, as they are
resolved, seem to lead to a new but similar plateau? With regard to
this question. Meadow (2003) notes, "The analyst accepts and pre-
serves these [the analysand's] perceptions until the patient can enter-
tain new ways of perceiving. Undifferentiated ego-object percepts will,
in this approach, become highly charged with emotion. Only then do
we deal with them as resistances" (p. 70).
 Modern Psychoanalysis Meets Andre Green: The Case ofZ D 43

Z left treatment again when I suggested that we work out a frequency

of sessions he could afford rather than build up a debt. He again said he
didn't need therapy. In response to a phone call, he declared "nothing
was happening" so he didn't need to come in, but he was reluctant to
get off the phone. I am waiting for a contact to begin the dance all over
again and see if indeed he can eventually become an analytic patient.
As Andre Green noted, "Analysis is not something you can predict; you
are always surprised by what happens."

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