Psychoanalytic Therapy and the Gay Man

Jack Drescher

• Publisher: Routledge
• Year: 2014
• eBook ISBN: 9781317771319
• Edition: 1
• Topic: Psychology
• Subtopic: Applied Psychology
• Index: Psychology

Do the conventional insights of depth psychology have anything to offer the gay patient? Can contemporary psychoanalytic theory be used to make sense of gay identities in ways that are helpful rather than hurtful, respectful rather than retraumatizing? In Psychoanalytic Therapy and the Gay Man Jack Drescher addresses these very questions as he outlines a therapeutic approach to issues of sexual identity that is informed by traditional therapeutic goals (such as psychological integration and more authentic living) while still respecting, even honoring, variations in sexual orientation.Drescher's exploration of the subjectivities of gay men in psychoanalytic psychotherapy is more than a long-overdue corrective to the inadequate and often pathologizing tomes of traditional psychoanalytic writers. It is a vitally human testament to the richly varied inner experiences of gay men. Drescher does not assume that sexual orientation is the entire or even major focus of intensive psychotherapy. But he does argue, passionately and convincingly, that issues of sexual identity - which encompass a spectrum of possibilities for any gay man - must be addressed in an atmosphere of honest encounter that allows not only for exploration of conflict and dissociation but also for restitutive confirmation of the patient's right to be himself.Through its abundance of first-person testimony from both clinical and literary sources, Psychoanalytic Therapy and the Gay Man provides the reader with an unforgettable grasp of what it is like to discover that one is gay in our society and then to find the courage and humanity to live with that knowledge. Any mental health professional - regardless of his or her sexual orientation - who wishes to deal therapeutically with gay men will find Drescher's work indispensable. But it will also be compelling reading for anyone seeking psychological insight into gay men's lives and concerns.

1
Introduction

I have also realized that individual psychoanalysis and sociology are, at base, essentially one field of study.

Harold Searles, "Dual- and Multiple-identity Processes in Borderline Ego-Functioning" (1977)

It is with a good deal of reluctance that the psychoanalyst undertakes to present a typology of behavior. . . . But although we therefore feel that the setting up of typologies is justified, it behooves us to be explicit about the shortcomings inherent in any such attempt.

Kohut and Wolfe, "The Disorders of the Self and Their Treatment" (1978)

Any attempt to turn a therapeutic discovery that emerges from a relational context into a technique that can be "applied" to other patients is an illustration of what I believe to be the single most ubiquitous failing in all analytic schools of thought as methods of therapy, and the shared blind-spot in each of their creators.

Philip Bromberg "Speak! That I May See You" (1994)

Psychoanalytic Therapy and the Gay Man? When Paul Stepansky of The Analytic Press suggested this as the title for my proposed book, I immediately associated to Helen Gurley Brown. In the tradition of Freud, whose theory of infantile libido ran counter to fin de siècle Vienna's prevailing beliefs about middle-class sexuality, Brown's 1960s book, Sex and the Single Girl, had an oxymoronic quality that drew attention to her time's cultural attitudes toward female sexuality. Since then, the sexual emancipation of women has challenged traditional gender stereotypes which inevitably led to the modern, cultural reevaluation of homosexuality. Today, a book that shows how a psychoanalytic psychotherapy can affirm the sexual identities of gay men is part of that growing cultural transformation.

It should be noted that Psychoanalytic Therapy and the Gay Man is not just a book about doing psychotherapy with gay men. It is also a chronicle of the historical state of relationships between two controversial cultural movements of the twentieth century: psychoanalysis and the political struggle for gay rights. It would be an understatement to describe the historical state of relationships between organized psychoanalysis and the lesbian and gay community as strained. What factors led to that estrangement? Not only had American psychoanalysis pathologized gay identities for many decades, but in the early 1970s, psychoanalysts were among the most vociferous opponents of deleting homosexuality from the American Psychiatric Association's official manual of mental disorders (Bayer, 1981). Furthermore, with a few rare exceptions, like the William Alanson White Psychoanalytic Institute in New York City, organized psychoanalysis insisted that gay men and women were unsuited to become psychoanalysts unless they converted to heterosexuality (Socarides, 1995, p. 153). Those days are all in the past. In the quarter century following the APA's 1973 decision, American psychoanalysis has undergone, and is still undergoing, rapid and radical changes in developing theories and attitudes that can be therapeutically helpful to lesbians and gay men. Across the country, even the most traditional psychoanalytic training institutions are now actively recruiting lesbian and gay candidates (Roughton, 1995). Most of these changes have taken place in the last decade, but they have not been well publicized. As a result, today's psychoanalytic theories and practitioners are still regarded with suspicion and hostility in many segments of the lesbian and gay community.

Why do I believe that this political history is relevant to psychoanalytic psychotherapy with gay men? In the postmodern world, personal and political narratives are not easily separable. From its inception, psychoanalysis claimed privileged access to the meanings of homosexuality. In fact, traditional psychoanalytic theories and attitudes, as they were communicated in the training process, actually reflected cultural biases against homosexuality. Because of this history, and the infantilizing and pathologizing attitudes that their theories subsequently fostered, many analysts found it difficult to consider alternative ways to think about homosexuality. I therefore believe that therapists have something to gain if they learn about the historical, political, and moral attitudes that surround the meaning of homosexuality. Not only will this allow them to understand the broader social implications of the clinical theories with which they work, it may also enable them to comprehend more fully the clinical narratives told by gay men in treatment. Of course, knowing something about gay patients is only part of the treatment. It is equally important for therapists to be consciously aware of their own feelings and attitudes toward gay men. And because I believe that psychoanalytically-oriented treatments are a significant research tool, Anne Fausto-Sterling's (1992) words are particularly relevant to therapists undertaking the exploration of gay patients' lives:

We ought to expect that individual researchers will articulate—both to themselves and publicly—exactly where they stand, what they think, and most importantly, what they feel deep down in their guts about the complex of personal and social issues that relate to their areas of research. Then let the reader beware. The reader can look at the data, think about the logic of the argument, figure out how the starting questions were framed, and consider alternate interpretations of the data. By definition, one cannot see one's own blind spots, therefore one must acknowledge the probability of their presence and provide others with enough information to identify and illuminate them

[p. 10].

In keeping with the above recommendation, I wish to state from the outset that this book is written by a gay male psychoanalyst. I work within an analytic perspective that sees the therapist as an agent of the patient, rather than as a representative of the patient's social milieu. In fact, I will explain and then argue against the positions of the psychoanalytically-oriented therapists, historical and contemporary, who overidentify with cultural expectations of traditional, gender conformity. I do not mean to suggest that therapists can or should ignore what are experienced by patients as social pressures to conform. The need to deal with external reality has always been part of the psychoanalytic model. However, Freud saw hysteria as a dissociative response to Victorian beliefs and attitudes toward human sexuality. His psychoanalytic method enabled his hysterical patients to take issue with sexual reality as it was defined in their time. Freud led the way by showing that only through the questioning of embedded cultural beliefs can analytic progress be made.

In addition to questioning sexual and gender conformity, I wish to name some of the other psychoanalytic values that inform this treatment approach. They include Winnicott's (1965) concept of the holding environment and Bion's (1967a) notion of containment. Both are therapeutic attitudes that create a setting in which a patient feels safe, respected, and accepted. In addition, I believe that Sullivan's (1954) detailed inquiry can teach a patient the value of curiosity. Curiosity can promote skepticism about authority, psychoanalytic or otherwise, as well as unravel what Sullivan referred to as the mystifications contained within authority's revealed truths. Curiosity can also foster integration by challenging a patient's dissociative tendencies. And, finally, I believe that awareness of and honesty about one's own fantasies, thoughts, and feelings are valuable and salutary, for both patient and therapist.

This book is primarily written for clinicians who have worked with gay patients, those who are currently working with them, or those who may have a desire to learn more about these men. However, I hope that this book will also be of some interest to anyone interested in learning more about psychoanalysis, psychotherapy, gay and lesbian studies, and queer theory. This book may also be of interest to any individual, regardless of his or her sexual identity, who is trying to understand the contemporary cultural debates regarding the meanings of homosexuality as our society tries to define a role for its lesbians and gay citizens.

Toward this end, I have tried to offer a glimpse of some developmental narratives that define some gay men's identities. Paradoxically, however, I cannot provide a singular definition of what it means to be a gay man. I do not wish to delimit the subject by defining it. In other words, I have not set out to write the definitive handbook about being gay. Gay male identities are not static entities because they vary according to time, place, and culture. The gay men of my generation are not like those of the generation before us, and younger gay men are different in other ways. For example, the distinguished anthropologist, Gilbert Herdt, along with the developmental psychologist Andrew Boxer, described a cohort system of four historical age-groupings of men in Chicago: (1) those who came of age after World War I; (2) those who came of age during and after World War II; (3) those who came of age after Stonewall and the period of gay activism around it; and (4) those who came of age in the era of AIDS (Herdt and Boxer, 1993). Their findings support my belief that all identities are culturally defined and that none of them can be captured by any one author's subjectivity, not even that of Herdt and Boxer.

Throughout this book, in discussing theories of homosexuality, I use quotation marks when the word "homosexual" is used as a noun. This is done to emphasize the point that being gay is not the same thing as being a "homosexual," The latter is a medical term that takes one aspect of a person's identity, his sexual attractions, and treats it as if it were the sum of his entire identity. Ln clinical practice, gay patients, like heterosexual ones, differ in temperament, personality, interpersonal relatedness, family background and cultural history. A therapist needs to remember that one is not just working with a gay man, but with a patient. It is the recognition and exploration of individual differences among gay men that should characterize a psychoanalytically-oriented treatment approach.

In trying to offer a meaningful, psychoanalytic way of working with gay men that respects individuality, ties past experiences to the present, and offers an increased awareness of their inner worlds and interpersonal relationships, this book tells what I think of as unofficial stories. My preference for this approach comes from the observation that official stories can obscure individuality. An official psychoanalytic story, such as the resolution of the Oedipus complex, will all too often legitimize only one path of development. Not only does this create a preferential developmental hierarchy, but in the hands of some psychoanalysts, official stories became authoritarian and disrespectful, as in Bergler's (1956) claim that "Homosexuals are essentially disagreeable people" (p. 228). Unofficial stories, on the other hand, can exist comfortably as nondominant narratives. They do not have to be imposed on everyone and, like countercultural narratives in general, their very existence subverts the official story's expectations of universality and conformity.

I also believe that this is not just a book about treating gay men. Freud took the idea of homosexuality and used it to make a case for his broader psychoanalytic concepts of bisexuality, libido, projection, paranoia, and narcissism (Freud, 1905, 1910a, 1911, 1914c). Conversely, psychotherapy with gay men touches upon many issues that are being contentiously debated in the modern psychoanalytic world. These include, but are not limited to, psychoanalytic epistemology; one-person versus two-person psychologies; the developmental influences of nature and nurture; the role of analytic neutrality; the very existence of neutrality; the role of subjectivity; the discovery of meaning versus the creation of meaning; the function of personal morality in clinical practice with implications for the influence of the therapist's beliefs on the conduct and outcome of a psychotherapy or analysis; the primacy of the Oedipus complex; the meaning of a developmental line; the nature of the unconscious; the uses of countertransference; therapist self-revelation; the psychoanalytic understanding of affects; and psychoanalytic pluralism.

I have made quite extensive use of quotes from the literature of gay studies, queer theory, psychoanalysis, sexology, religion, and reparative therapy. Paraphrasing does not always capture the tone of the original author's text and I often found that an author's tone played an important part in my affective experience of the material. If I call a particular psychoanalyst disrespectful, for example, it does not quite have the same effect as hearing, in his own words, the analyst's disrespectful tone. It is also my hope that in experiencing the wide range of authors' tones and the affective responses that they evoked, the reader may better approach the subjective experience of gay men. Thus, while reading the literature about homosexuality presented here, I invite the reader to hear the quotes as if he or she were a gay man. Listening to the voices quoted in this book was the closest approximation I could find to a gay man's subjective experience of his inner and external worlds. Those voices can be either soothing or harsh, accepting or critical; they will inevitably be contradictory. Although it was impossible to present the myriad attitudes toward homosexuality in one volume, the range offered here may provide therapists with some inkling of how gay men internally struggle to make sense of their same-sex feelings.

I have tried, perhaps unsuccessfully, to avoid sweeping recommendations and therapeutic prescriptions. Instead, my intent has been to illustrate a psychoanalytic attitude that is useful in understanding a particular life experience while recognizing individual variations within that experience. As a general rule, doing psychotherapy with gay men may entail more similarities than differences to the treatment of heterosexual patients. Consider the following patient, reentering treatment because of increased symptoms of depression and anxiety:

Patient: I read Darkness Visible by William Styron. A friend gave me the book. He does an excellent job of describing the anxiety attack, the feeling that one is losing one's mind and going mad. In a sense it is comforting to know that someone else is going through it and yet worrying that this poor guy could not get out of bed and had to check into a hospital. He did get over it. He said if it happens once, it's likely to happen again. This is the fourth episode of depression I've had.

Therapist: How do you feel about this being your fourth episode?

Pt: Enough is enough. This is the first time I understand what it is. I had experienced it before without knowing what it was. The interruption of sleep, etc. I never did anything about it before.

Th: You did come into therapy the last time you became depressed.

Pt: That's true. But this time I'm not suffering the breakup of a relationship. My feelings about Roger have passed. Now the depression is different. Now I'm questioning everything. What is debilitating is the feeling of worthlessness and inadequacy. It's kind of crippling. That's why I have the fantasy of working in a no-stress job. I have to eliminate stress or scale it back. I'm not sure if this high-powered career thing is a good thing for me. It's not making me happy. It's making me unhappy. In my state of mind right now, this pressure is crippling. I want to throw up my bands and say, "Screw it."

Without knowing the anatomical gender of this patient, the reader might not easily discern the patient's sexual identity. At this moment, in this particular session, the patient's concerns are indistinguishable from any of the issues that patients bring to therapy: emotional stress, difficulty with personal relationships, work relationships, or family relationships. And although an understanding of this patient's sexual identity will certainly be an important issue across the course of his treatment, it will not be the only subject talked about in therapy. It is difficult to quantify how much time is spent on issues related to gay men's sexual identities. And it would be yet another understatement to point out that the subject is rarely addressed in the psychoanalytic literature. My own clinical experience, in general, has been that approximately 10 to 15 percent of therapeutic time is devoted to discussing issues related to being gay. But having said that, it should be noted that a patient deeply engrossed in coming out will be highly focused on his gay identity for much of the time. Another patient, who may have been out for a long time, much less so. Therefore, it is not always possible to separate things out by percentages. Furthermore, a man's gay identity is linked to his multiple identities of child, parent, sibling, professional, patient, or citizen, just to name a few. So although a patient's gay identity is not necessarily the primary focus of treatment in many cases, its impact on the course of treatment cannot be overlooked.

This observation may escape a therapist who believes that treating gay patients requires no special knowledge. I have certainly heard therapists say, "I treat my gay patients just as I do my heterosexual ones." Laudable as this attitude may be, particularly within the context of psychoanalysis' historical animus toward gay patients, this belief ignores the fact that growing up gay is a different cultural experience than growing up heterosexual. There are specific issues that inevitably come up when a patient lives his life as a member of a sexual minority. One intention of this book is to explore, in a psychoanalytic context, how the larger world might look through a minority perspective.

My clinical approach is based upon my psychotherapeutic and psychoanalytic work with about one hundred gay men, and more than three hundred gay men seen in brief, office consultations, for a variety of reasons, since 1984. Although some of the patients I discuss are not gay, they have been included in this book because the issues they raised were relevant to the understanding of gay identities. While discussing these cases, I do not focus on frequency of sessions or whether the patient was seen face to face or on the couch. For the record, however, I see some therapy patients face to face, although most of them use the couch. Some patients came to treatment two or three times a week but most of them were seen once a week. Almost all of the patients entered treatment because they were in a crisis of some sort, usually accompanied by anxious and depressed feelings. None of them came seeking a didactic analysis. Several of the patients discussed in this book were only seen once or twice for a consultation. A significant minority were in treatment from six months to two years. The majority of the patients were in treatment for at least two years and some have been in treatment for as long as ten years.

Rather than presenting extensive case histories of individual patients, I have highlighted clinical and theoretical issues by relying either upon brief patient summaries or, more commonly, I have used edited transcripts of therapy sessions. The verbatim patient material was taken from process notes with over 40 patients, all of whom were told that S was writing a psychotherapy book. Although this may not give the reader the fullest sense of an individual patient, my goal was to cover a broad range of issues. The astute reader is likely to find both transferential and countertransferential subtexts contained in the clinical dialogues presented later. Sometimes these are commented on, but at other times they are not directly addressed. This does not mean, however, that they were never addressed. I am more than willin...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Contents
• Acknowledgments
• 1. Introduction
• 2. Defining A Gay Identity
• 3. Theories of the Etiology of Homosexuality
• 4. Therapeutic Meanings of Antihomosexuality
• 5. Psychoanalytic Theories of Homosexual Development
• 6. Reparative Therapies
• 7. The Therapist's Stance
• 8. Developmental Narratives of Gay Men
• 9. The Closet
• 10. Coming Out
• References
• Index