Notes from the Margins

The Gay Analyst's Subjectivity in the Treatment Setting

Eric Sherman

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781135060565
• Edition: 1
• Topic: Psychology
• Subtopic: Applied Psychology
• Index: Psychology

Much has been written about the impact of gender and sexual orientation on the intersubjective field. Yet remarkably little has been written about the unique dilemmas faced by gay clinicians who treat patients of different genders and sexual orientations. Given the particularities of growing up gay in our culture, issues of secrecy, shame, alienation, difference, and internalized homophobia necessarily enter into any gay therapist's developmental history. These factors have a shaping impact on the gay analyst's sensibility, on the way he learns to listen to his patients.

In Notes from the Margins, Eric Sherman courageously reveals a wide range of subjective reactions to eight different patients. In detailed clinical vignettes that highlight his thoughts, feelings, personal history, and countertransference struggles, he conveys the experiential immediacy of working as an analyst-and, more specifically, as a gay analyst. Although Sherman is not the first author to write thoughtfully about working in the countertransference, he is among the very few to portray analytic work, particularly in the working through of enactments, as an often untidy affair, marked not only by success but also by the blind spots and insecurities that contribute to failure. Notes from the Margins is not only an illuminating overview of the special challenges faced by gay and lesbian analysts, but a window to grasping the messy realities intrinsic to the psychotherapeutic process.

1
Introduction

Notes from the Margins is meant to defy one's usual expectations of a psychoanalytic text. The book's purpose, its format, even the way it came into being—nothing about it is traditional. It was conceived when Jack Drescher, editor of TAP's Bending Psychoanalysis series, invited me to dinner at a trendy (read, noisy) restaurant in Manhattan's popular Chelsea section. Over wine, Italian food, and the deafening din of dozens of conversations, we cooked up a novel idea: to do a book about what it is really like to work as a psychoanalyst, and specifically as a gay psychoanalyst. Toward that end, I would have to be willing to open up and show my work in all its messiness and allow myself to be vulnerable before the entire analytic community. I would need to talk about successes, failures, blind spots, and my own insecurities and countertransference quandaries. I felt both excited and frightened thinking about it.

Nevertheless, I felt compelled to take on the project. For in the last few years, two formerly overlooked and seemingly unrelated currents have captured the attention of contemporary psychoanalysts: (1) the importance of the analyst's subjectivity as it shapes the therapeutic interaction, and (2) the role, in treatment, of patient's and therapist's gender and sexual orientation. Yet, even as books and journal articles have explored these trends, two vital areas have been largely ignored—areas that Notes From the Margins addresses.

First, little has been written about the unique dilemmas homosexual clinicians face when seeing patients of different genders and sexual orientations, especially gay analysts' most intimate countertransference responses. Second, too many articles, even those written within the relational perspective to which I adhere, treat the analyst's countertransference as a neat and seamless variable. Countertransference is usually presented as a feeling or attitude that the therapist can easily reflect on and overcome with just the right intervention, even in the heat of the most tense moments. In pristine clinical vignettes, confounding and disturbing enactments are miraculously worked through by the brilliant analyst's perfect response, and the treatment is forever transformed.

While this may sometimes be the case, few articles or books capture the more common and intense struggles all therapists face. Often left out is how our very humanness—our backgrounds, personalities, morals, and the personal meanings of our sexual orientation and gen-der—can confound, torment, and even misguide us. As a result, many working psychoanalysts may feel ashamed, inadequate, or foolish about their "imperfect" work. More troubling is that many students of psychoanalysis are given the erroneous impression that a day may eventually come when they will be free of their countertransferences—or that they can entirely master them.

This book is an attempt to correct those impressions. It does so by providing a glimpse of a gay analyst's unique subjectivity in the clinical setting. Certainly, all therapists' subjectivities are shaped by their sexual orientation and sense of gender. However, when the therapist is gay, and his history is replete with issues of secrecy, shame, alienation, difference, and internalized homophobia, he inevitably brings a unique way of listening to his patients.

By presenting detailed clinical vignettes that highlight my thoughts, feelings, personal history, and countertransference struggles with different patients, I hope to offer a glimpse inside the workings of the analyst's mind. I aim, with some trepidation, to do something quite radical: to talk about what really goes on in the treatment room—the good, the bad, the ugly, and the uncertain. Although I have highlighted particularly charged moments in several different treatments, it is important to note that the day-to-day work goes on without fanfare and outside the spotlight. Yet even during relatively quiet, stress-free moments, our subjectivity remains forever engaged. For all those clinicians who have ever felt a sense of shame about their imperfections, I hope the revelation of my own experiences can engender a feeling of freedom rather than of isolation.

As for the format of this book, theoretical and clinical material are presented separately. Chapters 3 through 9 are each devoted to telling a compelling case history, filled with action and unencumbered by immediate theoretical discussion. The clinical cases are bookended by two chapters (2 and 10) that provide the theoretical underpinnings that inform my work.

Chapter 2 begins with an examination of the role of countertransference, starting from Freud, and then focusing on contemporary models of psychoanalysis. How we understand and use our countertransference is crucial to the outcome of any treatment in the relational model. By being in touch with our own feelings toward a patient, we develop a unique understanding of the patient's complementary feelings. In this way of working, enactments are inevitable and even welcome. They provide a distinctive glimpse inside the patient's internal world, as well as into the intersubjective field cocreat ed by patient and therapist.

In chapter 3, the first clinical account, I present my work with José, a gay man whose effeminacy evoked discomfort and homophobia in me. The more he lisped and fluttered his hands as he spoke, the more distant and judgmental I became. As an effeminate older man, he was everything I was afraid being gay meant when I first began my own coming-out process. It was not until José challenged me during a particularly meaningful enactment that I could see just how painful— and familiar—my distancing had become for him. Working through my fears of being like José was a turning point in the treatment.

Chapter 4 highlights my work with Rich, an insecure straight man whose aggressive posturing was in stark contrast to José's "fluttery" effeminacy. Yet Rich made me feel just as insecure about my own masculinity. He and I spent much of the treatment engaging in power struggles as I worried that my homosexuality would be found out and ridiculed. Then a package delivered to my home-office brought with it a tense standoff between Rich and me.

Chapter 5 introduces the theme of sexual excitement by presenting two cases of erotic countertransference with heterosexual patients. In the first, I dissociated from my own desire for an attractive straight man for fear of being found out. As a result, he became increasingly more depressed as he undoubtedly responded to what he perceived as a lack of interest on my part.

I was much more comfortable—and flirtatious—with a seductive young heterosexual woman who had a history of coming on strong to men and then feeling spurned. By allowing myself to feel excited by her interest in me, I gave her a new experience in which sexuality and intimacy went hand-in-hand rather than being split off. Thus the patient could enter her first loving relationship—with her future husband.

In chapter 6, my fantasies about being a loving heterosexual father embroiled me in an enactment with a new mother who brought her baby to session for seven months. My failure to confront her colluded with her wish to have the perfect husband and father and to avoid her anger. When I finally confronted the patient, her hurt feelings and anger burst forth, and I was left searching for a way to welcome these new emotions without losing the patient.

In chapter 7, I present my work with a middle-aged gay virgin. Steve was so cut off from his desires that I succumbed to his sense of deadness and distance by enacting one of a therapist's (and patient's) worst nightmares—I fell asleep during a session. Rather than discuss how he felt when he saw that I was asleep, Steve was eager to ignore what had happened to avoid embarrassing both of us. Along with a number of dreams that showed his concern about whether I was truly awake and interested in him, this enactment helped me to understand better Steve's fears that his needs would go unrecognized by me, just as they had been ignored by his parents.

Chapter 8 finds me feeling aroused by a photograph a gay patient brought in of himself in a bathing suit. My mind races as I decide how to handle this important, yet uncomfortable, clinical moment. Ultimately, with much nervousness, I find a way to use my erotic feelings to help bring alive a treatment that until that point had become sanitized and barren.

Chapter 9 also touches on my sexual excitement, this time for a gay man who enacted with me his domination and submission fantasies. When Adam told me he refused to use a condom during sexual intercourse, I found out firsthand what it was like to be powerless, just as the patient felt in his real life. Ultimately, he contracted HIV, and together we had to struggle with the feelings this aroused in each of us, including anger, sadness, and self-blame.

The book's final chapter discusses specific dilemmas that the gay analyst faces in working with heterosexual and homosexual clients alike; it puts into context the clinical chapters that precede it. I examine how the gay analyst is not immune from feelings of internalized homophobia that come from growing up in a society in which being gay means one is saddled with a sense of difference and shame. How he struggles with these feelings makes all the difference between deepening the therapy and getting stuck in an impasse.

Notes from the Margins provides a glimpse of how a gay analyst uses his countertransference in his work with gay as well as straight patients. Each of the patients stirred up in me strong emotions, emotions I could not simply ignore. In presenting these cases, I hope you will get a real sense for how I understand and work with my subjectivity as it intermingles with that of the patient.

There are many challenges in writing a book that is so clinically detailed. One is to protect my patients' anonymity. While the cases in this book are all real, a number of them are composites intended to conceal the patients' identities. In all the cases, some identifying information has been changed.

Another challenge has been to make this book accessible to all readers, regardless of their sexual orientation. Every analyst—gay, bisexual, or straight—struggles with issues around shame and guilt, hiding and being seen. This book not only gives therapists permission to have these feelings, it shows them how to utilize them in the treatment.

It is my hope that this glimpse inside my consultation room stimulates discussion, self-reflection, and even criticism. As I share my own process, I hope you will feel freer to do the same. Psychoanalysis is an isolating profession. The more we have a sense of going through this together, the more we, and our patients, will benefit.

2
The Analyst’s Subjectivity

Working analytically requires the analyst to expose his¹ greatest vulnerabilities. Each chink in his personality armor, every insecurity, every doubt, conflict, and uncertainty, and all the ghosts from his childhood are rustled up countless times a day as he struggles to find ways to be helpful to the human beings who have entrusted him with their pain, their hopes, and their emotional well-being. It is a tall order—humbling, but also terribly exciting.

No matter how well analyzed an analyst is, his subjectivity is always alive in the room, constantly stirred by and intermingling with his patients' transferences. A therapist can find himself feeling needy with one patient, unappreciated with another, and impotent with a third. These feelings are often painfully familiar and go back to the analyst's own developmental history. The more familiar the feelings, the more likely the therapist is not to notice or to avoid them and to enact them with the patient. Yet each countertransference reaction is also shaped by the interaction with the patient and is provoked by how he needs to see the analyst as a familiar object from his own past (Mitchell, 1988). I feel needy with patient A not just because I have my own experiences of longing, but also because patient A has his own history of unmet desires. He can project that neediness into me rather than feel the painful wishes again within himself. Similarly, if patient B acts in an aloof way, his inability to recognize my subjectivity may trigger a countertransference reaction of "What about me?"

Historical Views on Countertransference

Psychoanalysis has always asked that clinicians know themselves as well as possible. However, the field's conceptualization of countertransference and ways of understanding and using a therapist's subjectivity has changed over time. Freud (1910, 1912) saw countertransference as representing unresolved unconscious conflicts and deficits in the analyst's personality. Since transference was conceptualized as distortions from the patient's past that were projected onto the analyst, the therapist, through self-analysis, needed to eliminate all personal interferences that would hinder the development and understanding of the transference. Freud (1912) believed an analyst needed to obtain a high degree of objectivity. He cautioned,

I cannot advise my colleagues too urgently to model themselves during psychoanalytic treatment on the surgeon, who puts aside his feelings, even his human sympathy, and concentrates his mental forces on the single aim of performing the operation as skillfully as possible [p. 115].

In contrast, Freud's disciple Sándor Ferenczi (1931, 1933) argued that a patient's transference to the analyst might not be due entirely to historical distortions. In addition, not only might a therapist have a range of feelings toward his patients—such as loving and hating, seducing and disappointing—but patients are astute at discerning their analyst's countertransference.

In the 1950s, a number of writers (Heimann, 1950; Little, 1951, 1957; Benedek, 1953; Racker, 1953, 1957; Tower, 1956) took up the issue of countertransference as an inevitable consequence of the analytic situation. These writers, along with later contributors like Searles (1975) and Sandler (1976), wrote from a "totalistic" standpoint. That is to say, using a broader definition of countertransference than the original one, they saw it as a therapist's total response to the patient, both conscious and unconscious, one that takes all the analyst's personality into account.

Over time, psychoanalytic theorists began to understand countertransference as something that could be useful in the work. Many of these theorists were influenced by Kleinian thought or by that of other adherents of the British object relations school. D. W. Winnicott (1949) noted how an analyst's comfort with his hatred for the patient allowed the patient to feel more comfortable with his own aggression. Heinrich Racker (1968) labeled as a "distortion" the belief that analysis

is an interaction between a sick person and a healthy one. The truth is that it is an interaction between two personalities.. .. each personality has external and internal dependencies, anxieties and pathological defenses; each is also a child with his internal parents; and each of these whole personalities—that of the analysand and that of the analyst—responds to every event of the analytic situation [p. 132].

Racker, however, believed that countertransference was induced by the patient and that any competent analyst would have the same countertransference with that patient: the patient's projecting his neediness into the analyst evokes a generic, infantile state of mind that would be the same in any therapist.² In other words, even a well-analyzed analyst would not bring his unique personality and responsiveness to...