The Psychoanalytic Treatment of Homosexuality - Mitchell, S.A. (2002)

(2002).
Studies in Gender and Sexuality, 3(1):23-59

The Psychoanalytic Treatment of Homosexuality: Some
Technical Considerations
Stephen A. Mitchell, Ph.D.
In the psychoanalytic literature on the treatment of homosexuality, one
particular point of view, which I shall designate the directive-suggestive
approach, has attained the greatest visibility and notoriety. A survey of the
most widely cited writings on the psychoanalytic treatment of homosexuality
over the past 20 years reveals a recurrent admonition to the analyst to depart
from the traditional analytic position of nondirective neutrality by actively
discouraging homosexual behavior and encouraging heterosexual behavior. It
is argued not only that the analyst should take an open stand against
homosexual behavior, but that any meaningful treatment of such patients must
entail such a stance. Despite the fact that this approach violates several
fundamental principles of sound psychoanalytic practice, and despite the fact
that it is therefore highly unlikely that this approach is representative of the
broad practice of most psychoanalysts with patients who are homosexual, the
directive-suggestive approach is often
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This paper, originally published in the Int. Rev. Psycho-Anal. (1981, Vol.
8, pp. 63-80), is reprinted here, with only minor editorial and stylistic
revisions, with the permission of the publisher of that journal.
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taken to represent the predominant psychoanalytic point of view. This false
impression, both by practitioners within the mental health field as well as
among the lay public, is partly a result of the relative absence in the
psychoanalytic literature of differing viewpoints. This has allowed Jerome
Frank (1972), for example, to make what seems to be the descriptively
accurate statement that “most analysts, insofar as they describe what they do,
seem more or less explicitly to devalue homosexual impulses and actions and
encourage the patient to make heterosexual approaches” (p. 13, italics added).
In a previous publication I offered a critical appraisal of those theoretical
positions within psychoanalytic theory which presume the inevitable
pathology of homosexuality (Mitchell, 1978). In this paper I would like to
explore some technical and ethical issues in the psychoanalytic treatment of
homosexuality, which are raised by a consideration of this most visible
approach within the literature. In particular, I explore dangers in relation to
compliance and defiance in the transference, and the more general question of
influence in the psychoanalytic situation. I argue that the preoccupation with
behavioral change inherent in such an approach distorts and undermines the
basic process of psychoanalytic inquiry central to the power of
psychoanalysis to effect deep and significant characterological change.
Most psychoanalysts approach homosexual material produced by their
patients as they would any other experiences of their patients—simply as
material to be inquired into and analyzed. Such analysts are not likely to write
about psychoanalytic approaches to treating homosexuality, since they would
tend to feel that homosexuality does not pose particularly distinctive or unique
features in terms of analytic work. Such a point of view would therefore be
underrepresented in the literature, which seems to reflect the position of those
with a proverbial axe to grind in relation to homosexuality, viewing it as
something out of the ordinary, posing unique technical problems and requiring
a departure from the traditional analytic process.
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This misleading impression is partly responsible for the extremely
negative attitude toward psychoanalysis found in many sectors of
the gay community. In this paper I take a close look at this most
visible point of view, explore some of its implications and dangers,
and illustrate some of the issues by considering the initial phases of
the analytic treatment of a patient, who, in a previous analysis, had
renounced an exclusively homosexual orientation.
The Literature on Treatment
In surveying the history of the psychoanalytic treatment of homosexuality it
is useful, as with most issues, to begin with Freud. Freud was rather
pessimistic about the possibility for analytic reversals of homosexual
orientations. “In general, to undertake to convert a fully developed
homosexual into a heterosexual does not offer much more prospect of success
than the reverse” (Freud, 1920, p. 151). This therapeutic pessimism was
grounded in Freud's theoretical belief that constitution played an important
role in many, and a predominant role in some, cases of homosexuality. In
“The Psychogenesis of a case of Homosexuality in a Woman,” where he
discusses these issues most extensively, a cure was not possible, both
because of the “congenital” origins of the homosexual orientation (p. 169) as
well as because of the presence of a strong, vindictive transference toward
the father, which Freud felt necessitated a referral to a female analyst.
Nevertheless, in his reflections on this case, Freud makes two important
points concerning technique, which are interesting in relation to contemporary
writings on the analysis of homosexuality. First, Freud suggests that the
chances of success in such cases are minimal when the patient himself has no
interest of his own in changing his sexual orientation.
As is well known, the ideal situation for analysis is when someone
who is otherwise his own master is suffering from an inner conflict
which he is unable to resolve alone, so that he brings his trouble to
the analyst and begs for his help.… Any situation which differs
from this is to a
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geater or lesser degree unfavorable for psycho-analysis … [p.
150].
By contrast, as we shall see, several contemporary writers not only
believe it is possible to alter homosexuality even if the patient has no interest
in doing so, but that it is the responsibility of the analyst to insist on this as a
goal of statement. Second, Freud notes the salience of compliance and
defiance in the treatment of homosexual patients. As he explains, the woman
in question was, on one hand, submitting to analysis in compliance with the
father's wishes, while, on the other hand, intensely desirous of revenge and of
sabotaging the treatment. Freud notes further that frequently homosexuals enter
treatment with the “secret plan” of orchestrating a dramatic failure to be
“cured” of homosexuality, hence freeing them subsequently to “resign”
themselves to this sexual orientation with a clear conscience (p. 151).
Although Freud's early awareness of the centrality of compliance and
defiance in homosexual patients has been developed in many of the theoretical
discussions of homosexual dynamics, the implications of these dynamics for
the stance the analyst takes vis-à-vis sexual orientation in the treatment has
been largely and peculiarly ignored.
As critical questions began to be raised concerning the concept of an
inherent, congenital basis for homosexuality, more optimistic voices were
raised concerning the possibilities for altering homosexuality. As early as
1909 Ferenczi took issue with Freud's views, arguing, as many would
subsequently, that all homosexuals were heterosexual at heart and that
homosexuality is most usefully viewed as a defense against conflict-laden
heterosexuality (pp. 173-174). Although Fenichel (1945) refers to the poor
prognosis that was widely assumed for the psychoanalytic treatment of
homosexuals, he notes several papers in which a more optimistic view was
taken. Harnik, in a line of thought developed later by Ovesey, suggests an
extension of analytic technique analogous to that suggested by Freud for
phobias, in which heterosexuality is viewed as the phobically avoided
situation, participation in which the analyst actively encourages (Fenichel,
1945, p. 367).
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Other early ardent voices arguing the pathological nature of all
homosexuality and its potential transformation through psychoanalysis
included Bergler (1959) and Kolb and Johnson (1955). The latter argued that
analytic neutrality is disastrous for treating patients with homosexual
dynamics, since it is inevitably experienced by the patient as a repetition of an
original unconscious parental encouragement of homosexual activity and
thereby exacerbates rather than cures the homosexuality. These authors reveal
a tendency of most writers suggesting directive-suggestive technique in
treating homosexuality—a preoccupation with actual behavior at the expense
of the quality of the relatedness and the nature of the internal experience of the
patient. Also, since neutrality is routinely transferentially distorted by all
patients to mean all sorts of things, both enticing and withholding, it is not
clear why with homosexual patients Kolb and Johnson feel such distortions
cannot be interpreted, but must be counteracted before they occur by active
antithetical actions of the part of the analyst.
There seems to have been a growing consensus during the 1950s that
homosexuality is psychodynamically derived, pathological, and potentially
treatable. However, there was not yet a clear consensus concerning what sort
of approach might facilitate cure, and the Kolb and Johnson model was
certainly not universally accepted. Several writers, for example, stressed the
importance of the conviction on the part of the analyst that homosexuality was
pathological, but avoided actual prohibitions (S. Feldman, 1956; Eidelberg,
1956). This uncertainty was reflected by Eissler (1958), who noted that there
is no psychoanalytic technique for perversions in general. It was not until the
early 1960s that clear, fully detailed approaches to the treatment of
homosexuality began to emerge, entailing deviations from traditional analytic
technique. The major proponents for this suggestive-directive approach were
Bieber, Ovesey, Socarides, and Hatterer. We shall consider each of their
positions in turn.
Irving Bieber (1965) presented such an approach, derived from research
published three years earlier in which he and his coauthors studied the
psychodynamics and origins of
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homosexuality as well as the results of treatment. The latter, interestingly,
were determined exclusively in behavioral terms—that is, whether the patient
had become exclusively heterosexual, was bisexual, or had remained
exclusively homosexual. Bieber does not suggest overt prohibition of
homosexual activity and, in fact, notes that patients entering analytic treatment
are apprehensive precisely about such prohibitions. He deviates from
nondirective neutrality not by coercion but by explanation, “education,” and
prediction of the future course of treatment.
I inform the patient that heterosexuality is desirable for many
reasons to be elucidated as the analysis proceeds, but that he will
neither be pushed nor tricked into it … the curtailment of
homosexual activity per se does not promote heterosexuality, but as
relevant problems and fears are resolved, the latent heterosexuality
begins to emerge [p. 261].
It is as if the patient is to be the passive recipient of an inevitable process
which the analyst foresees, which will result in his eventual transformation
into a heterosexual.1
Lionel Ovesey (1969) proposed a more active departure from analytic
non-directive neutrality in treating male homosexuality, following a series of
fascinating papers on the psychodynamics of homosexuality and
“pseudohomosexuality” (homosexual fantasies or behavior where the
sexuality serves as a vehicle for power and dependency motivations).
Derived from Rado's view that homosexuality is a phobic avoidance of
heterosexuality and the female genital, the treatment is directed at inducing the
patient to enter the phobic situation. “There's only one way that the
homosexual can overcome his phobia and learn to have heterosexual
intercourse, and that way is in bed with a woman” (pp. 106-107). The
performance of heterosexual intercourse is the goal, while interpretation of
related dynamic issues concerning power, dependency, and the dangers of the
vagina constitute a means to that end (p. 107).
—————————————
1 Glover (1955) has characterized approaches to treating homosexuality that
avoid actual prohibitions, but that make clear the analyst's convictions as to
the undesirability of homosexuality as a “crypto-Ferenczi policy” (p. 316).
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The therapist must establish from the outset the principles upon
which the treatment is based:
1. Homosexuality is pathologic. It is not a natural biologic phenomenon.
2. The homosexual act is an overdetermined symptom with specific
unconscious meanings.
3. Homosexuality is a treatable illness. Through treatment, the normal
heterosexual direction of the sexual drive can be reestablished.
These assumptions provide the therapeutic framework within which
the therapy is conducted. They must be reiterated again and again
throughout the therapy [p. 119].
If the patient does not enter treatment feeling that his homosexuality is a
problem, the therapist should challenge this and define it as such. Ovesey
further asserts that analysts who “lack conviction” that homosexuality is both
an illness and treatable should not work with homosexual patients.
The treatment proceeds with what Ovesey describes as “pressure” from
the therapist on the patient for the latter to date women. Retreats into
homosexual behavior are neither forbidden nor condoned, since interdiction
may be unbearable and precipitate a flight from treatment. Ovesey does not
completely reject the use of ultimatums threatening the end of treatment
(which Kolb and Johnson, 1955, had urged), but feels they should be directed
not toward retreats into homosexuality but toward “insufficient efforts to
perform heterosexually” (p. 121). Homosexual activity is interpreted as a
prima facie manifestation of resistance and disadvantageous to the progress of
treatment. When the patient does establish a relationship with a woman, if
neither he nor the woman initiates sexual behavior, the therapist should
suggest it. With patients who have difficulties responding to this steady but
relentless pressure, “the therapist should commit the magic omnipotence with
which he is unconsciously endowed in the transference, and guarantee
ultimate success” (p. 123). The ultimate therapeutic goal cannot be simply full
potency with women, since, Ovesey argues, the
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temptations for backsliding will be too great. The ultimate goal must be a
“successful marriage,” although the criteria for “success” in this context are
not elaborated. Each of the three case vignettes he reports ends with a
“stable” marriage and children.
Socarides (1968) proposed a view of homosexuality derived from an
extension of Mahler's developmental model in which he sees homosexuality
largely as a preoedipal fixation involving an intense symbiotic union with the
mother. He argues that the depth and severity of the underlying conflicts
makes psychoanalysis the treatment of choice for homosexuality, but that the
ego impairments that are consequent to the severity of the pathology
necessitate various alterations in technique; and he lists “educational and
retraining measures, more intensive supportive interventions and
modifications in the handling of the transference, resistance, and regression”
(p. 211). Socarides primarily devotes himself to an exploration of the
intricate dynamics in several lengthy cases and does not present in detail
exactly what is involved in the alterations in technique that he suggests. He
does make it clear, however, that he feels that homosexuality lacks any
redeeming features.
The “solution” of homosexuality is always doomed to failure and even
when used for utilitarian purposes, that is, prestige, power, protection by a
more powerful male, the accomplishment is short-lived.
Homosexuality is … filled with aggression, destruction, and self-
deceit. It is a masquerade of life.… Instead of union, cooperation,
solace, stimulation, enrichment, healthy challenge and fulfillment,
there are only destruction, mutual defeat, exploitation of the partner
and the self, oral-sadistic incorporation, aggressive onslaughts,
attempts to alleviate anxiety, and a pseudo-solution to the
aggressive and libidinal urges which dominate and torment the
individual [p. 8].
Socarides also makes it clear that the analyst should communicate these
views to the patient as part of the reeducative
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process. He argues that in the early phases of the treatment it is necessary for
the therapist to undermine the patient's “rationalization” involving various
defenses of his homosexuality as being a variety of normal. Throughout, the
analyst must make the patient aware of what Socarides feels is the enormous
selfdestructiveness and hostility inherent, by definition, in any homosexual
encounter (pp. 135-137). “It is important to discourage him from a
masochistic display of his homosexuality to spare him added guilt and shame
with increased isolation” (p. 217). He suggests that an outright prohibitory
attitude toward homosexual activities is possible. Throughout his cases and
discussion of technique, there is an active encouragement of a positive
transference and “identification” with the analyst, often based on a
denigration of the parents, the mother for her sadistic intrusiveness and the
father for his passivity and ineffectuality. Socarides sees this identification
with the analyst as crucial in the transition from homosexuality to
heterosexuality, since it provides the patient with what was missing
developmentally—a good father to help him break his emasculating,
symbiotic tie to the mother.
The patient's turning to heterosexual relationships often coincides
with a strong positive transference. In the positive transference the
patient is able to identify himself with the good father and thus
achieve in the transference what he has been unsuccessfully trying
to achieve in homosexual relationships, namely, to get possession
of the good father's penis and become free of his enslavement to the
mother [p. 227].
Hatterer (1970) proposed an approach to treating homosexuality that, on
the surface, appears to differ in important respects from those considered so
far. He stresses the importance of openness in goals of treatment, the
avoidance of stereotyped definitions of healthy maleness and the value in
treating “committed” homosexuals for other problems without insisting that
they pledge themselves to a change in sexual orientation. Nevertheless, the
treatment approach he proposes
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for those not totally committed to homosexuality consists of a directive stance
on the part of the therapist to induce the patient to alter his behavior.
This encouragement of what Hatterer calls the “dehomosexualization
process” includes reassurance of the therapist's respect and liking for the
patient, encouragement (”you're on the right track,” p. 104), tales of other
successful treatments, various techniques for willful mind control for
distraction from homosexual impulses and fantasies, exploitation of the
patient's sense of shame (“any expression of shame, alienation and distrust
can be used to thwart his resistance,” p. 126), and propagandizing of various
sorts. The patient is warned against the “slim possibilities of success for a
permanent homosexual relationship” (p. 126) (presumably heterosexual
attempts are not met with warnings about the growing divorce rate). Religious
values which “emphasize ethics, the family and the necessity to lead an
integrated experience shall be used by the therapist in a way that can reinforce
motivation to change” (p. 63). Finally, the therapist provides a social critique
and moral leadership. “Your goals couldn't be sounder, there's nothing corny
about being romantic, we need more romance in our society. It's full of plenty
of the masturbatory, the impersonal, and you want to get out of those patterns
and shed those values … which is fine” (p. 139).
The kind of approach proposed by Bieber, Ovesey, Socarides, and
Hatterer has dominated the psychoanalytic literature on homosexuality over
the past two decades and has been assumed by many to represent the general
psychoanalytic position. However, there have been occasional warnings
against such an approach and its potential for undermining the psychoanalytic
process. A. Freud (1954) provides an interesting discussion of some of the
issues. She notes that the general principle one would follow in cases of
homosexuality entails a modification of Ferenczi's original stress on active
prohibitions, in which the analyst asks the patient “to postpone the
pathological form of satisfaction for periods of increasing lengths while
tolerating as much as possible of the ensuing anxiety to intensify the
treatment” (p. 338).
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She goes on to present two cases, one in which this principle was
destructive and consequently abandoned, and one in which it was useful. In
the former case, the patient's homosexual activity was understood as
representing a projection of his own phallic strivings onto other men, and a
subsequent recapturing of those strivings through the homosexuality. A. Freud
suggests that to ask this patient to give up homosexual activity was equivalent
to a request for self-castration and hence was counterproductive. In the latter
case in which she felt the prohibition of homosexual behavior was useful, the
homosexual behavior served the patient as an “addiction.” As this addiction
was prohibited, addictive features began to emerge in the relationship to the
analyst. A. Freud suggests that, once in the transference, the addiction could
be employed to “hold down the fort” until the unconscious material has made
its appearance and could be analyzed. What seems extremely important in her
treatment of this case is her self-conscious use of the transference to bring
within the scope of analytic inquiry material that was being acted out
elsewhere, with an awareness that such a maneuver temporarily intensified
and encouraged the compliant and passive transference to the analyst. A.
Freud suggests that this should be seen as a stopgap measure to expand the
scope of the analytic inquiry, with the subsequent intensification of
compliance and addiction in the transference being anticipated and
necessarily worked through. This stress on the centrality and the dangers of
compliance and passivity in the transference is precisely what is most lacking
in other discussions of this treatment technique.
Several other authors have gone further and argued that any stance by the
analyst in opposition to the homosexual behavior is both counterproductive
and unethical. Romm (1965), in discussing female homosexuality, argues that
“the therapist has no right to set such personal goals for his patient and should
certainly not stress his desire to plan to remake her into a heterosexual
individual” (p. 299). Mintz (1966), in an article on treating homosexuals
through simultaneous individual and group therapy, stresses the importance of
the therapist's not demanding any commitment by the patient to be “cured” of
the
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homosexuality; and also, in contrast to Hatterer and others, argues that shame
and guilt and fear of social disapproval must be relieved, not exploited, in
order for the patient to deal with the more basic conflicts (p. 194).
Problems with the Directive-Suggestive Treatment Model
The treatment of homosexuality by the directive-suggestive approach
already delineated presupposes that homosexuality is invariably pathological
and that a change to heterosexuality is necessarily in the service of the
patient's greater health and happiness. These assumptions are unproven. One
major disadvantage of this approach is that, by taking such a strong,
directional stand, the analyst eliminates the important questions from
emerging for analytic inquiry and study. To declare homosexuality to be
pathological and heterosexuality desirable, and to use various types of
pressure to induce the patient to change his behavior from one to the other,
eliminates the possibility of finding out what the patient would do on his own
as a consequence of psychoanalytic inquiry into his experience. I have
demonstrated in a previous publication (Mitchell, 1978) that the presumption
of the pathology of homosexuality is an artifact of psychoanalytic history,
conceptually unsound and antithetical to modern theoretical psychoanalytic
understanding. There is also a growing body of empirical evidence that
clearly runs counter to such a presumption, as Gonsiorek's (1978) massive
review of the literature suggests:
This leads up to a major theme of this paper. The question of
whether homosexuality per se is pathological has been as resolved
as it ever will be. More and different samples may, and probably
should be collected, and data collection on new and different
samples will be important and interesting in its own right.
However, it is clear that the bulk of data do not support a position
of inherent psychopathology in homosexual behavior. Further
research on this question will likely have the quality of knocking
down straw men. The questions now, which are both theoretically
fascinating and socially relevant are: which homosexuals are
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psychologically disturbed; what factors can count both for their
disturbance and the lack of disturbance in some of their peers; why
do some homosexuals become disturbed; can those homosexuals
who will be maladjusted be identified early; and what interventions
are most appropriate for these persons [p. 27].
In presuming to know the answer a priori, the active, nonneutral treatment
approach precludes the possibility for analysts to contribute meaningfully to
the study of these questions, as well as to the larger question of the
possibilities for, and conditions facilitating, intimacy in heterosexual as well
as homosexual relationships.
An additional factor limiting the potential contribution of psychoanalysis to
the larger question of the relationship between sexual orientation and intimacy
is the tendency of writers advocating this treatment approach to focus on overt
behavior and not on the quality of internal experience and object relations.
There is no particular attention paid to the nature of the homosexual contacts
and the quality of the relatedness. Exclusive heterosexuality or “stable
marriage” is used as a criterion for successful analysis of homosexuals,
without a further look into the quality of the heterosexual relatedness. Why is
the patient now heterosexual? Does the transformation have conformistic
roots? Is it mechanical and exploitative? Does it arise from spontaneous
gestures and longings?
These questions are not often raised, since the behavior, or, more
concretely, the type of genitals the patient is juxtaposing to his own, is seen as
containing all the relevant information. This preoccupation and the neglect of
internal experience and the quality of relatedness are not simply omissions,
but seem to constitute an inevitable feature of any approach that determines
health in primarily behavioral terms and seeks to use the analytic situation to
alter behavior. (This misplaced emphasis was one feature of what Freud,
1910, described as “wild analysis” (p. 223). It is interesting that in the
preface to their 1962 study Bieber and his coauthors mention that they chose
to study homosexuality partly because it was a “clearly defined behavioral
pattern which would not present any diagnostic difficulties”
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(p. vii). It may be that the ease with which homosexuality and heterosexuality
can be defined behaviorally presents a potentially dangerous temptation,
enticing some psychoanalysts away from a deeper inquiry into the subtleties
of character and internal experience towards the clear yet deceptive realm of
behavioral change. A costly clarity.
What is the process through which patients treated with the directive-
suggestive approach alter their behavior from homosexual activities to
heterosexual activities? Almost all theoretical discussions of the dynamics of
homosexuality in the literature stress the centrality of compliance,
submissiveness, and passivity, either out of fear of the oedipal rival or
connected with pregenital dynamics related to dependency and symbiosis.
Bieber perhaps states it most strongly: “The psychodynamic kernel of the
homosexual trend in both males and females is submissiveness or the fear of
submitting to a member of the same sex who is perceived as powerful and
threatening” (p. 263).
One would imagine that an understanding of these dynamics would alert
authors writing about treating such patients to the obvious dangers of such
compliance manifesting itself in the transference, resulting in the patient's
adapting his surface appearance and behavior in conformity with what he
perceives to be the therapist's goals and values. On these grounds alone, one
might argue that the therapist ought to take a position only of extreme
nondirectiveness, to remain carefully alert to the state of the transference, and
to be suspect of behavioral changes in the direction of what the patient takes
to be the analyst's values. The authors in question obviously do not reach such
a conclusion, but what is most striking is that despite their understanding of
the original dynamics, they seem either naively unaware or else simply
unconcerned about the extent to which the approach they urge makes
behavioral changes motivated by a compliant transference likely, and the
extent to which their own case illustrations strongly suggest this possibility.
We can see this most clearly in the case material supplied by Ovesey (1969)
and Socarides (1968).
Ovesey is, to some extent, mindful of the transferential implications of his
approach and in fact consciously exploits the transference in his inducement
of behavioral change. In
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each of the three cases he presents, submissiveness and compliance are
central to the dynamics and manifest themselves directly in the transference.
Following the therapist's proclamation that homosexuality is a treatable
psychiatric illness from which the patient should want to be cured, patient 1
has the following dream: “He turned to the lobby of the building in which he
lived only to find it completely rebuilt overnight. Everything looked elegant,
shiny, strong and new. He was amazed at the transformation” (p. 128). In
commenting on this dream and its portrayal of the magical, transformative
powers of psychoanalysis, Ovesey notes the “rather marked suggestibility” of
the patient, which “at the beginning … served to mobilize intense activity
toward a heterosexual existence” (p. 129). Patient 2 displays a similar
transference: “Most evident was his desire to ingratiate himself with the
therapist through success with women, but this motivation served the needs of
the therapy and at the beginning was deliberately not analyzed” (p. 139). In
both cases, the therapist chooses to exploit rather than to interpret the
transference. Ovesey notes the “earmarks of a transference ‘cure’” in the
“improvement” in patient 1, but reports that “as long as the transference was
useful in mobilizing heterosexuality activity it was thought best to leave it
alone” (pp. 130-131).
Is it also possible to interpret and work though a transferential integration
that the therapist has been exploiting consistently to induce behavioral
change?2 In the necessarily sparse clinical material Ovesey provides it is
clear that, until the patient has established a stable heterosexual pattern of
behavior, the therapist consistently interprets away from compliance in
transference and in the direction of encouraging behavioral change. Although
Ovesey talks of these transferences as subsequently being “faced” and
resolved, the obvious difficulties inherent in such a reversal are not
discussed.
In the one brief account of such a moment in the treatment, the therapist
deals unconvincingly with the problem by a dodge.
—————————————
2 Freud (1912) also speaks of using the positive transference to motivate the
patient before analyzing it, but in the service of inquiry, not of altering
behavior.
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This example involves patient 2, who, after much pressure from the
analyst, goes to bed with a prostitute and that night dreams: “He was in the
woods. He was a male fox among many others and one of the foxes inserted
anally into him. Then all the foxes, including the patient, changes into men” (p.
140). This dream is interpreted as a flight from heterosexuality to a “magical
repair through homosexual contacts” (p. 141). Ovesey does not consider the
possibility that the dream represents the patient's experience of being
dominated and overpowered by the therapist, who has pressured the patient
into the heterosexual situation. The therapist's interpretation of the dream, in
fact, seems to have been experienced as further domination and control.
Following some dating and sexual experiences with women, the patient has a
“series of dreams with homosexual content. In a typical dream he was fighting
off a man at the door, who wanted him to perform fellatio” (p. 142). Only
after the patient himself interpreted the man at the door as representing the
therapist does the issue of compliance in the transference become an open one
in the treatment. The patient expressed his “feeling of being forced by the
therapist to relate to women or risk the therapist's displeasure if he did not.”
Ovesey described the resolution of this issue as follows:
The therapist felt … that this was the time to interpret the patient's
misconception that he was in therapy for anyone's sake but his own.
The patient's first reaction to the interpretation was to be
discouraged, a not uncommon reaction to an interpretation of this
kind. He took it to mean that his sexual conquests of women were
not genuine, but were due somehow to the therapist. He was
reassured on this point, that it was he who had succeeded, and after
a few days of discouragement, he tried again [pp. 142-143].
This interaction is extremely interesting in that it brings into sharp focus
what seems to be the necessary contradiction and bad faith inherent in a
procedure that both actively exploits and claims to analyze the transference.
As Ovesey had made clear, until this point the patient has altered his behavior
largely
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out of motivation to please and ingratiate himself with the therapist. The
patient now acknowledges this through his dream and his associations,
describing his feeling of being coerced. The therapist does not validate these
correct perceptions, nor does he explore their implications, but counters with
a non sequitur pointing out the “patient's misconception that he was in therapy
for anyone's sake but his own.” The patient becomes upset as he realizes,
accurately, that his heterosexual behavior had something to do with the
pressure from the therapist and his compliance to that pressure. At this point
the therapist is in a real dilemma—if he acknowledges the validity of the
patient's concern, he threatens to undermine the behavioral alterations he has
been struggling to win. If he does not, he is really denying the reality of the
patient's accurate perception of what has taken place. The therapist in
Ovesey's report chooses the latter course. “He was reassured on this point,
that it was really he who had succeeded.”
Hatterer (1970) provides another example of a therapist using a similar
directive-suggestive approach, getting caught in the same dilemma:
P: Every time I show the slightest degree of interest in getting out of
this furtive world I've been wandering about in, your expression
becomes very animated. You seem to open your eyes wider, you
lean over and listen to me more carefully. I even get the feeling that
you're less bored with me when I get off the subject of these
endless, elaborate accounts of my sex life. I wonder if you don't
like me more when I'm not so preoccupied and have other things on
my brain.
T: It's very true, your observations are an accurate reflection of
what's going on between us … except for the observation that I'd
like you more as a person if you changed. I hadn't realized that I
appeared bored with your accounts of your sexual exploits, but it's
probably true to some degree as they're repetitious and have been
very destructive to you. You too may be getting bored with the one-
dimensional life you're
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leading. You seem to have indicated this quite often in recent
sessions, and I think this awareness should really help motivate
your change [p. 130].
In this exchange the patient states his accurate perception of the therapist's
clear investment in the patient's values and behaviors, and his own concern
with pleasing the therapist, thrusting the issue of compliance into the treatment
in a way which demands response. This might have been taken as an
opportunity to open up an exploration of the nature of the patient's sensitivity
toward the therapist's impression of him, his submissive longings in relation
to the therapist, etc. Instead, the therapist acknowledges the patient's
perceptions, but explains his own values and pressure for behavioral change
by reference to what he claims is the destructiveness of the behavior for the
patient himself. He then suggests that the patient may feel the same thing, has
seemed to indicate an attitude and values similar to the therapist's recently,
and further proclaims his belief that this “awareness,” which now is wholly
attributed to the patient himself, should motivate the patient to change. With
this sleight of hand, the patient ends up at the same place he began before he
raised the issue of pressure and ingratiation—he's been told what's good and
bad for him, what he is aware of, and how he should change. Thus, neither
Ovesey nor Hatterer has demonstrated how it is possible both to exploit
compliance in the transference to produce behavioral change and then
subsequently to interpret and resolve such a transference, nor how the basic
contradiction in the position can be handled in good faith with the patient.
Socarides's (1968) case material provides another striking example of the
possible connection between the transition to heterosexuality through the
active, nonneutral approach and submission to the analyst. Because he sees
homosexuality as deriving most fundamentally from severe disturbances in the
separation-individuation process, Socarides is generally mindful of the
dangers of regression and excessive dependency in the transference. “There
exists … a passive receptive attitude to interpretation …” (p. 215).
“Dependency strivings should be
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adequately controlled in as much our goal is to achieve a higher level of
integration” (p. 224).
Yet the whole approach Socarides takes to the patient in regard to his
sexual orientation is directive, educative, and filled with a certainty about
what behaviors are best for the patient. As explained earlier, Socarides feels
that the transformation from homosexuality to heterosexuality is made
possible by an identification with the analyst as “good father.” As the
following quote suggests, Socarides seems to achieve this “identification” at
least partially through a detailing of the “actual” faults and deficiencies of the
patient's parents.
The analyst explained to Patient A how to conduct himself in a
heterosexual relationship. He showed him by diagrams that there
was nothing to fear and that he certainly could have heterosexual
intercourse. The analyst constantly exposed the ruthless and
irresponsible, fearful and sick, totally negative and destructive
behavior of the mother and the patient gained courage through
facing up to this reality. He began to emulate the analyst's objective
appraisal of the mother's behavior and lift himself out of his
unconscious masochistic sexual submissiveness to her. Many times
he requested advice, helpful criticism and insightful knowledge
from the analyst about handling current life problems and human
interactions in his professional and social circles. This was his
education by a new, good father who would protect him against his
crushing mother and inept, inadequate and weak real father. He
became a man and was not afraid to become so through this positive
identification [p. 114].
What is taking place in these exchanges? Is there a working through of the
attachments to the parents and a real individuation with an integrated, digested
identification with the analyst; or has the symbiotic attachment to the mother,
who has now become vilified, simply been replaced by a submissive,
symbiotic tie to the analyst, who seems to present himself as a paragon of
virtues, now expressed by the acting out in behavior
- 41 -
of the analyst's as opposed to the mother's values and wishes. Interestingly,
the patient's first intercourse with a woman was immediately preceded by the
following dream.
“You're being on top of me. We are not having intercourse but you're
telling me, forget my real father and you're my father and not to tell my
mother about it. We were clothed. And then you got up and left. It was
very nice. But you didn't really leave. You just got up.” This dream
preceded heterosexual intercourse by a few hours. He stated in
association that he was beginning to have a good relationship with his
father. He felt more confident of his masculinity. It was like the analyst's
telling him to be a man [p. 109].
In this dream, strikingly similar to Ovesey's patient's dream, Socarides's
patient is in the sexually “inferior' position vis-à-vis the analyst, whom he
experiences as urging him to abandon his real parents and take him, the
analyst, as a parent. This is a patient whom Socarides sees as having grave
difficulties with separation-individuation. Yet he assumes that the
immediately subsequent heterosexual behavior is a product of a much more
differentiated object relation, deriving from the transference to the analyst as
a “good” father. This is despite the fact that this “good” relation is expressed
in the dream through the metaphor of sexual submission, which, as Socarides
describes elsewhere in the case, the patient uses to perpetuate his hostile,
symbiotic tie with both parents.
In having intercourse with a male he was forcing his father to give
him the affection and love which he could not acquire passively or
actively in childhood. In addition he was substituting the penis of
the male for the female breast (mother) and was enjoying disguised
sexual intercourse with her [p. 111].
It seems at least equally as likely, and not at all considered by Socarides,
that the patient was using the analyst as an alternative mother, but that there
was no greater differentiation or change
- 42 -
involved, just a shift in content. The patient was submitting to the analyst as
the dream clearly implies, just as he had to the mother, but now symbiosis
with and submission to the parental figure entailed adopting heterosexual
behavior.
The preoccupation with behavior that the directive-suggestive approach
maintains is based on an implicit assumption generally held throughout that
heterosexual behavior is invariably motivated by a genuine erotic
responsiveness, arising spontaneously, and is not influenced by other
motivational processes; in contrast to homosexual behavior, which is assumed
to be motivated either by nonerotic, pregenital motivations or else by a
defensive retreat from a more basic heterosexual erotism. Hence, the meaning
of the behavior is defined, almost solely, by its behavioral manifestations.
Although it is clear from the case material that much of the heterosexual
behavior in question is motivated, at least in part, by efforts to please and
comply with the analyst, the implications of this in terms of the
meaningfulness or authenticity of the actions to the patient himself is not really
considered.
One aspect of this omission seems due to a conceptual unclarity concerning
the meaning of the concepts of “activity” and “assertiveness,” in which the
behavioral referents of these terms are blurred with the object-relational
meanings. As noted earlier, passivity, compliance, and submission are
constantly mentioned in the discussions of the dynamics of homosexual
activity. Phallic assertiveness and heterosexual interests are understood as
having been renounced in connection with, depending on where one places the
predominant fixations, either the mother's intrusive possessiveness or the
father's competitiveness and defensiveness. In the psychoanalytic treatment of
such a patient, one might well consider one goal to be the overcoming of his
anxieties connected with activity and assertiveness—a breaking of the
passive, dependent attachments to the parents.
The question arises, however, as to how much activity and assertiveness
are to be determined. In the approach in question, if the patient acts actively,
assertively, or heterosexually, the assumption is made that such activity
involves an implicit character change—the tie to the parent is being broken;
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something new is happening. However, if this change has come about partly
because the therapist has continually communicated to the patient, “Be active,
be assertive, be heterosexual,” the possibility must be considered that the
change is a continuation of the original passivity and submission, with the
analyst substituting for the parent in the transference. The behavior is active,
but the patient adopts it because of his passive, submissive relation to the
object. The activity in behavior is merely a vehicle for the perpetuation of
passivity in the internal and external object relations. In adopting an active,
nonneutral stance, the therapist can be seen not only as “exploiting” the
transference, but as gratifying it, by playing out the role of the all-knowing,
all-powerful, directing parent, as a complement to the compliant surrender in
the transference of the patient. As Glover (1995) has pointed out, such
transference gratification tends not to produce structural change, but tends to
“anchor the repetitive situation in the present” (p. 171). The behavioral
alteration is not a product of change, but of perpetuation. Such behavior might
well be considered, to adapt Ovesey's term, a “pseudo-heterosexuality,” with
little connection to any spontaneous impulses, wishes, or desires emerging
within the patient, but rather an internalization, whole cloth, of the therapist's
values and goals, a reflection of what Winnicott (1960) called the “false self
on a compliant basis.”
A. Freud (1952), discussing the classificatory types of homosexuality,
suggests that classification be made not in terms of the overt behavior, but in
terms of the fantasy, active or passive, accompanying the act, consciously or
unconsciously. One might follow the same process in evaluating all sexual
behavior in general, focusing not on the behavior itself, but on the fantasies
and internal relatedness to the major significant objects, including the analyst.
The result of pseudoheterosexual cures might well be a person who functions
heterosexually, but who experiences the same sense of internal emptiness and
detachment that may have brought him into treatment in the first place.
Another aspect of the directive-suggestive approach which I would like to
consider more closely is the consequences of failed treatment, which seem
particularly important with this approach,
- 44 -
since even the most optimistic authors report only a small percentage of
“cures” or conversions to exclusive heterosexuality (e.g., Bieber et al., 1962)
report a 27% cure rate). What is it like for patients who undergo costly and
time-consuming analytic treatments, urged on by reports of other cures
(Hatterer, 1970), predictions of cures (Bieber, 1963), or guarantees of
success (Ovesey, 1969), but who fail to be “cured”? These approaches entail
a methodical labeling, as resistances to “cure,” of any recourse to homosexual
contacts, political affiliation with gay rights groups—indeed, anything but an
eager and optimistic attitude toward conversion. With the analyst either
overtly or covertly urging a behavioral transformation that in the large
majority of cases does not take place, the result can be only a profound sense
of failure, shame, self-hatred, and a deep cynicism about the analytic process.
Examples of such cases of failed treatment are not provided by adherents of
this approach.
Harold Brown (1976), however, provides a vivid account of his
experience in analysis in his autobiography Public Faces, Hidden Lives.
Brown describes his torturous years in analysis when, urged on by his
analyst's prohibitions and encouragements, he isolated himself from the
homosexual contacts through which he had experienced at least some intimacy
and sharing and forced himself into sexual situations with women, only to fail
miserably. He persevered because of the analyst's encouragement and
predictions of success. Brown describes his growing feelings of shame, total
isolation, and despair. Of course, one might point to what appears to have
been Brown's own need for self-mortification and redemption, and his
masochistic willingness to continue in a self-destructive process. However,
the analyst's collusion in these processes must also be questioned. If Brown's
account of his analysis can be taken as reflecting a general verisimilitude, and
it is certainly not at all inconsistent with what we have seen in the most
visible approach within the literature (if not within the actual practice of
psychoanalysis) on treating homosexuality—the analysis appears, in effect, to
have acted out a countertransferential scenario in which the patient is allowed
to demonstrate and find confirmation for his worthlessness, incapacity, and
social failings. What would have happened if the analyst's stance
- 45 -
regarding his homosexuality did not so neatly fit what we are hypothesizing
was Brown's masochistic transference? Would he have become, over the
course of the analysis, more interested in women? Would the quality of his
homosexual relations have been enriched? We'll never know.
One thing that does seem clear is that the active, nonneutral approach to
treating homosexuality is perfectly suited for the facilitation of the kind of
“secret plan” that Freud (1920) warned of in relation to homosexuals entering
analytic treatment—the staging of a dramatic treatment failure, as well as
other possible secret plans: defiance of society, self-humiliation, or a
continually frustrated hope for redemption. One cannot help wondering what
percentage of those who fail to be “cured” by the directive-suggestive
technique are designers, witting and unwitting, of such transferential projects,
whose ends are furthered by the analyst's taking on the desired role of moral
standard bearer and powerful agent of social redemption. A commitment on
the part of the analyst merely to inquiry would, of course, not obviate such
transferential intents, but would avoid the analyst's facilitating them. It would
also give the analyst a more meaningful place to stand, from which to interpret
the transference. Further, the majority of analysands who end up as something
other than exclusively heterosexual would be able to value their gains in self-
understanding, rather than bear a stigma of guilt, blame, and failure.
A final drawback of the directive-suggestive treatment approach to
working with homosexual patients is its tendency to block a full articulation
and working through of the transference, as well as to mask various
countertransferential developments. There has long been a consensus
concerning analytic technique that the establishment and the dissolution of the
transference is the central vehicle for analytic inquiry and character
transformation. Constant attention is paid to the transferential implications of
all the patient's communications, and often material seemingly concerned with
people external to the relationship with the analyst is interpreted into the
transference. It is in this context that the tendency of the directive-suggestive
approach to ignore the transferential implications of the patient's homosexual
behavior, compliance
- 46 -
to the analyst's values, dreams of sexual submission, and so on seems most
puzzling. One cannot avoid the strong suspicion that, if a female patient
brought in similar material—sexual experiences consistent with what she felt
were the analyst's wishes for her, dreams of being physically beneath the
analyst or penetrated by an anonymous male figure, the transferential
implications of this material would at least be strongly considered, if not
employed interpretively. Why the reluctance to use this conceptual and
interpretive framework particularly with homosexual male patients working
with male analysts? The possibility that anxiety in the countertransference is a
central factor here must be considered. Kwawer (1980) in a recent
publication points to the absence in the literature of any considerations of the
role of countertransference in working with homosexual patients. (See
Racker, 1968, for a discussion of common homosexual fantasies in the
transference and countertransference related to negative oedipal themes.) The
directive-suggestive approach appears to ward off homosexual feelings and
fantasies both in the transference and in the countertransference. A
consequence of this avoidance, amounting to, in effect, a denial of the
transference neurosis for homosexual patients, may be that the patient is
deprived of the opportunity to work through his central structural difficulties.
Case Example
The case of Mr. A offers a unique illustration of some of the processes just
hypothesized concerning both “successful” changes in sexual orientation as
well as treatment failures, since Mr. A was “cured” of his homosexuality
during five years in an earlier analysis and then returned, dissatisfied, for
further analysis with a second analyst. This change in analysts high-lighted,
through repetition, many of the transferential themes that had made possible
the “cure” of his homosexuality during his earlier analysis. The following is a
report of the beginning phase of treatment with the second analyst.
Mr. A, a sporadically employed photographer, had entered treatment in his
mid-20s because of chronic, deep depressions with suicidal ideation. These
depressions were often connected
- 47 -
with his participation in short-term, homosexual relationships in which he
appeared to be looking for an older man to take care of him, only to be
repeatedly and painfully disillusioned. He was a passive-dependent character
with work inhibitions and lack of goals. Over the course of his first analysis,
Mr. A had given up his homosexual activities. He no longer acknowledged
homosexual fantasies and had sexual relations with and eventually married a
woman who was a colleague of the analyst. The analyst moved, somewhat
precipitously, to another city, forcing what analyst and patient both felt was a
premature termination of Mr. A's analysis. Following a year's hiatus, he
returned to treatment, complaining of a general sense of purposefulness, lack
of assertiveness, and work inhibitions. Sexual activity with his wife had all
but ceased prior to the announced departure of the analyst, although this did
not seem particularly troubling to Mr. A.
Mr. A was the youngest of five children born to an upper middle-class
couple living in a large Eastern city. His parents were both professionals. Mr.
A's mother was an extremely depressed woman who, because of maternal
deprivation she herself had suffered, saw herself as a particularly hurt and
“sensitive” person. The father was a very detached, secretive, and resigned
man, who was a severe martinet with his children and on rare occasions
exploded with bursts of anger. The mother had suffered a postpartum
depression following the birth of each child, but the most severe followed the
birth of the sibling immediately preceding Mr. A. She was hospitalized for
two years, apparently mute most of the time. The father pleaded for her return
to life to no avail, until she finally emerged from her depression with the
resolve to have another child, who she assumed would be a girl.
Mr. A was born instead. The most striking feature of his childhood was a
very intense, mutually idealizing relationship with his mother. She was greatly
preoccupied with his cleanliness and reports having given him suppositories
at the age of seven months in an effort to control his bowel movements. As he
grew older, they shared a worldview in which they were different from
everyone else and exquisitely attuned to each other, particularly
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in their “sensitivity” to the mother's depression. The father, who had felt
guilty and somehow responsible for his wife's earlier hospitalization,
apparently gave over his youngest son to his wife's ministrations. Mr. A was a
very “good” boy. He felt himself to be different from other boys and men,
more “sensitive,” caring, and refined. Although the content of his earliest
sexual fantasies were homosexual, he would masturbate into one of his
mother's old bedspreads, which he concealed in his closet and later buried.
He began having homosexual affairs upon moving away from home to go to
college, and it was the frustration he felt in connection with these
relationships that led him increasingly to the despair for which he sought
treatment for the first time.
His initial presentation of his first analyst to his second analyst was of a
highly idealized figure who had saved his life by his kindness and wisdom.
He felt that he himself had a special facility as a psychoanalytic patient and
that he had become his former analyst's prize patient. He spoke of
psychoanalysis as if it were a religion to which he and both analysts belonged
that gave meaning to life and offered a suitable explanation for everything. He
spoke of his “neurosis” and particularly of his former homosexuality as if he
were speaking of sin, now renounced and behind him. Despite this account,
his first dram in his second analysis was: I was at a carnival or boardwalk.
Nixon was there in his shirtsleeves, passing out leaflets, asking people to
vote for him. I'm there feeling very sorry for him. I want to somehow
protect him. His associations to Nixon were to the first analyst, although he
had trouble accounting for the meaning of the pathetic, huckster image in the
dream. It was only much later, after considerable work had been done, that he
was able to talk about negative feelings about the first analyst and, finally,
similar feelings about the second analyst. He saw both, allowing some
differences in details, as rather incompetent, depressed, and lonely figures,
filling in their lives with patients.
The initial transference to the second analyst was characterized overtly by
a pervasive compliance, in which the analyst was idealized, in a fashion
similar to the patient's idealization of his wife and first analyst. The analyst
was all-knowing and perfect,
- 49 -
and Mr. A by being a good patient, was safe and protected in his care. As
long as he handed over to the analyst what the latter desired, his “dirty
secrets,” he would eventually be “cured.” He would provide, with great
facility, interesting dreams, slips, associations, and interpretations of his own,
always ceding to the analyst a final interpretive statement, which he would
receive as truth, and work assiduously at elaborating. However, his status as
a patient also entailed his endurance of what Mr. A felt were various
humiliating indignities, such as the analyst's note-taking and reticence. The
compliance and pseudocollaboration were punctuated by outbursts of rage
and a deep contempt when he felt particularly misused or insulted. The affects
and thoughts within these rages, it soon became apparent, were split off from
his ordinary state of mind, and after the rages he would have great difficulty
remembering them, dismissing them as some strange, “neurotic” aberration.
Mr. A's sexuality was employed by him in the service of his compliant/
defiant transference. He saw the analyst (I will use the singular to stand for
both analysts) as representing “normality” or society at large, pervaded by a
deep sense of moral righteousness, taking a highly condemnatory stand toward
his former homosexuality and any current homosexual fantasies.
Homosexuality was sinful and unquestionably bad and wrong. The analyst
demanded that he renounce this evil and convert to heterosexuality, and Mr.
A's involvement as a patient in psychoanalysis entailed an apparent surrender
to this moral demand. When these beliefs were clarified, his deep conviction
and insistence that the analyst did indeed have such a moral investment in his
transformation emerged.
As the second analyst questioned this conviction, Mr. A gradually became
aware of the following underlying beliefs: heterosexuality is boring and
vapid; the analyst's own life is empty and dismal; he needs to pretend it is
“good” and “right,” and particularly to have the patient join him in this self-
deception. This surrender to what he felt were the analyst's desperate needs
was experienced by Mr. A as motivated by the deepest love, entailing his
transforming himself to accord with what he felt were the moral standards of
psychoanalysis as a world view. Nevertheless, he also hated the
analyst/mother for
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his weakness, vulnerability, unavailability, and self-deception and used his
homosexuality as an ultimate defiance of the mother/analyst—a defiance he
kept hidden.
Despite his overtures to heterosexual transformation and his self-
mortification for his “sinful” homosexuality, he secretly felt homosexuality to
be superior, more exciting, more vital, and more alive. It became clear that it
was in his homosexual fantasies, which he kept for himself, that he felt most
spontaneous and real. This part of himself, which the mother/analyst could not
reach, even with her cleansing and regulating suppositories/interpretations,
was where he secretly lived. The heterosexual transformation that had taken
place in his in his first analysis appeared to be a “pseudoheterosexual”
vehicle for the expression of his submission and surrender to the
analyst/mother, and a defense against the deeper, more vital, and also hostile
and defiant homosexual feelings that he felt he needed to keep out of the
appropriative grasp of the analyst.
As the then current transference was clarified and worked through, the
structure of the essentially identical transference to the first analyst was
necessarily uncovered. This reconsideration of his experience and the
heterosexual transformation which was seen to be a crucial element in it, was
exemplified in the following dream, early in his treatment with the second
analyst:
Mary [his wife] and I were in the hands of some strange person … he
was very psychopathic, very charming … he was going to perform
some possibly dangerous experiments on us … they had sexual
overtones … I was intrigued and frightened … he had Mary and me on
the bed … he started to touch her legs … when he got to the top of her
thighs, I told him to stop
The association to the man in the dream, because of certain physical
characteristics, was to the first analyst. The dream was understood as
reflecting, among other meanings, his sense of the close involvement of his
first analyst in his heterosexual experiences and his own conflicts concerning
this involvement. A later dream, after much work had been done in clarifying
the transference to both analysts, seemed to reflect a sense of
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discontuinuity and inauthenticity relating to his earlier behavioral change.
Mary and I were living in an apartment that was kind of shabby … the
walls were in bad shape … there were holes in the floor … It was on
the second floor of a two story building, above another apartment … I
began to look more closely at the walls and floors … I suddenly
realized that the building had not been designed originally as a two
story building … Someone, at a later date, had just tacked on this
second story apartment, and not very well, without any concern for the
structural integrity of the building.
As the central transference configuration of compliance/defiance to the
mother was worked through over the course of the second analysis,
homosexuality was freed from its use as a previous bastion of vitality and
defense against surrender to the intrusive mother. Homosexual fantasies and
activities emerged, with new dynamics and transferential meanings.
Subsequent themes connected with homosexuality included:3 (1) The
emergence of feelings of playfulness and competitiveness in the context of
male camaraderie (e.g., a pissing contest) and a playful teasing in the
transference. (2) A longing for recognition from the father, expressed through
fantasies of exhibitionism and voyeurism, within and outside of the
transference. (3) The use of homosexual fantasies in the transference, and
provocative, seductive behavior, to recreate the original erotic/sado-
masochistic tie to the mother. (4) The use of homosexuality as a defense
against newly emerging heterosexual feelings toward the mother and other
women, so as to preserve the mother as pure. (His homosexuality also served
to protect her from his rage at her for what he felt had been her seduction and
betrayal of him. Sex was seen as dirty, powerful, and dangerous—a woman
could never survive being the object of his sexual desire.
—————————————
3 A full exposition of the dynamics and meanings of Mr. A's homosexuality
is not possible within the scope of this paper, with its focus on the subtleties
and transferential implications of changes in sexual orientation over the
course of analysis.
- 52 -
Homosexuality also preserved, in his fantasy, his flimsy relationship to his
father, since it represented his renouncing his own sexual claims on his
mother, allowing the father to keep her. (5) The use of nonheterosexuality as a
symbolic and apparent sexlessness, preserving his role as the daughter who
rescued the mother from her psychosis, and his identification with what he
experienced as the dead, depressive core of his mother, to which he felt
eternally pledged and bound.
The initial transference of compliance/ defiance reemerged at intervals
throughout the analysis, particularly in the service of resistant retreats from
newly emerging anxieties. Throughout, the idea of psychoanalysis as a set of
ethical and religious norms, with the analyst as priest, was a persistent
transferential obstacle to authentic self-inquiry and spontaneous development.
There were many dreams of churches and priests, and after a highly
significant fight with his wife in which he for the first time challenged her
infallibility, Mr. A said, “Last night I lost my temple—I mean temper.” As
this recurrent transferential structuring of relationships was worked through,
there was an enrichment of Mr. As relations with both men and women. He
developed, for the first time, deep friendships with men, who were no longer
only an occasion for a sexualized defiance of the mother. In his relationships
with women, Mr. A no longer acted only in a submissive or defiant way, but
began to allow himself more spontaneous reactions to them, including sexual
and aggressive feelings. It became possible for him to experience women as
having an authentic sexuality of their own.
The disentangling of Mr. A's central transferential configuration with the
second analyst allows a glimpse into the process of “cure” in the first
analysis. The change in sexual orientation did not derive from a deep
characterological change, but was a vehicle for the repetition of the basic
structure of his attachment to his mother, reenacted in the psychoanalytic
situation. He became heterosexual for the analyst, seemingly renouncing his
“sinful” homosexuality, in the same way he had become the dutiful child his
mother had desired, seemingly renouncing any angry, anal or, indeed, any
spontaneous feelings. It is not possible, at this point, to determine how the
first analyst handled the central transferential paradigm, which, according to
Mr. A, was simply not interpreted. What is most useful in
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this case is its illumination of a mechanism of apparent “cures” of
homosexuality with the analytic situation. The directivesuggestive, behavior-
oriented approach to treatment which has been the subject of this paper
clearly maximizes the likelihood of this kind of pseudoheterosexual,
pseudocollaborative “cure.”
If homosexuality is approached, alternatively, as one deals with any other
analytic material, in the spirit of open inquiry, we find that homosexual
fantasies and behaviors reflect a multiplicity of meanings and themes, the
analysis of which moves the treatment forward, permitting the patient to make
his own choices, free from influence, either overt or covert. The sexual
orientation chosen by patients at that point is a subject for future study. The
more purely analytic approach recommended in this paper (which is, I
believe, more representative of practicing psychoanalysts in general)
precludes the possibility of the patient's using the analytic situation in the
service of some “secret plan,” establishing the analyst as a bastion of moral
righteousness or the good life, which he either complies with or defies.
Conclusions
Psychoanalysis has been much besieged by criticism in recent years. On
the one hand, it is charged with doing little—other forms of therapy are seen
as more effective, less time-consuming, more productive of pragmatic
changes. On the other hand, psychoanalysis is accused of doing too much—
psychoanalysts are seen as having assumed a powerful social role, vacated by
the decline in other social institutions, combining the functions of the priest
and the policeman, establishing ethical norms and inducing people to act in
conformity with these norms. The specter of the “therapeutic state” has been
forewarned, in which analysts either wittingly or unwittingly became quasi-
political functionaries of forces much larger than themselves. In the midst of
these contradictory changes, it seems crucial for psychoanalytic practitioners
to be clear on what they can and cannot do, what they can offer in good faith
and what they cannot, and what in psychoanalysis is unique and distinct from
other forms of therapy.
- 54 -
At the center of this process of definition, and at the heart of any
determination of the social role and function of therapy, is the question of
influence. Freud established psychoanalytic treatment as distinct from
hypnotic and other forms of suggestion, as a process whose cure derived not
from the influence of the analyst, but from the self-inquiry of the patient.
Although the transference might be exploited to help motivate the inquiry
itself, cures based on transferential motives rather than on self-understanding
were felt to lack deep structural change, and hence durability. Psychoanalysis
distinguishes itself from other therapies precisely in this centrality of insight,
as opposed to behavioral tinkering, varieties of sensory experiences, physical
rituals, social exchanges, and so forth. Certainly transference has become
more and more central in our understanding of the analytic process, but not as
a means of influence. Rather, the working through of the transference has
become the tool of inquiry par excellence, the most powerful means ever
devised by which patients can rid themselves of the unintegrated, undigested
influence of others, encased as structural residues within the psyche. It is
because of this that psychoanalysis in its purest form is actually a powerful
retardant to social processes moving toward a “therapeutic state.” An
adherence to the principle of inquiry separates psychoanalysis from whatever
social context it may find itself in, allowing it, in its purest form, to remain an
apolitical and asocial process, and thereby freeing it from the dangers of
influence, either explicit or implicit.4 It is in this context that the departures
from traditional analytic inquiry in the direction of pressuring for behavioral
change, which, as we have seen, pervades the most visible approaches within
the literature on the treatment of patients who are homosexual, is particularly
disturbing.
There has been much recent controversy among theorists of behavior
therapy concerning values and treatment, particularly in relation to
homosexuality. Several writers have argued that
—————————————
4 Kohut (1979) in a recent publication, speaks of the crucial importance of
the analyst's relinquishing a “health and maturity morality” and “restricting
himself” to inquiry.
- 55 -
the client must determine the goals, regardless of social deviance (Feldman
and MacCulloch, 1971; Davison and Wilson, 1974). One writer has recently
suggested that, given the highly prejudiced and irrational social climate of
attitudes toward homosexuality, any wish, even on the patient's part, to change
sexual orientations must be viewed as suspect and not freely chosen, and has
therefore called for a moratorium on all attempts at therapeutic change of
sexual orientation (see Gonsiorek, 1978, p. 39). In these discussions,
psychoanalysis is characterized, in contrast to behavior therapy, as inherently
“value laden” (Davison and Wilson, 1974), which, as we have seen, is, in
some cases, certainly descriptively accurate although inconsistent with the
principles that make psychoanalysis a form of treatment distinctive from other
therapies.
Early psychoanalytic theories did not pay a great deal of attention,
explicitly, to the problem of values in connection with treatment. This was
partly because early psychoanalysis took place in a social setting in which
there was a great consensus and homogeneity concerning values. Neurotic
symptoms, in classical symptom neuroses, were understood to be
pathological. Perversions, whether alterable or not, were considered
undesirable. As a consequence, the problem of the analyst's values influencing
the choices of the patient was of less concern. Freud warned against
educative efforts, but more because of their lack of therapeutic durability than
because of any doubts about the rationality of universality of the values he
held.
We work today in a social context of extreme homogeneity and multiplicity
of values, in which life styles, sexual behavior, and shifting norms come and
go like yesterday's fashions. Classical-symptom neuroses are a rarity, and in
working with patients suffering from character disorders, any simple
delineation of which behaviors are to be viewed as healthy and desirable, and
which as pathological and undesirable, becomes less and less possible.
Subtle differences in internal experience, sense of self, and relatedness with
others become more and more important. It has become impossible to
determine the internal meaning and significance of experiences by simply
looking at the behaviors, no matter how “assertive,” “selfactualized,” and
“liberated.” Nevertheless, psychoanalysis itself is looked toward for
behavioral standards and moral direction.
- 56 -
In this context, the dangers of influence have become enormous. If
psychoanalysis is to remain the most radical form of human transformation, it
must rest on value-free inquiry. Departing from this process by transmitting
values overtly or covertly through the influence of the analyst may, perhaps,
be a more effective instrument for altering behavior. Yet, the price of this
possible increase in efficacy is clear indeed, both for those who are “cured”
as well as for those who are not. For the former, behavioral alterations occur,
but the repetitive, maladaptive internal structures remain and, in fact, may
have been reinforced, while for the latter, the experience in analysis leaves
behind a residue of shame and self-blame.
Summary
This paper provides a critical appraisal of what I have designated as the
directive-suggestive approach, which has dominated the analytic literature on
the treatment of homosexuality. I demonstrate that this approach rests on
unproven presuppositions, a conceptual unclarity concerning the nature of
activity and passivity, and an overvaluing of behavioral alterations at the
expense of internal, structural factors. I further suggest that behavioral
changes obtained through such an approach seem to be the result of a subtle
interplay between compliance and defiance in the transference. The
implications of the failure to deal adequately with themes of compliance and
defiance in the transference are considered, both in cases resulting in
“success” and in “failures.” The possibility that this approach functions as a
defense against homosexual themes in the countertransference is also
considered. These issues are illustrated in a presentation of the analytic
treatment of a patient who, in a previous analysis, had renounced an
exclusively homosexual orientation. An examination of the directive-
suggestive approach to the psychoanalytic treatment of homosexuality opens
up important questions concerning the nature of influence with respect to
psychoanalytic inquiry in general.
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Article Citation [Who Cited This?]
Mitchell, S.A. (2002). The Psychoanalytic Treatment of Homosexuality. Stud.
Gend. Sex., 3(1):23-59

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