See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/14530861

The “Erotic Transference”: Some Technical and Countertransferential

Difficulties

Article  in  American journal of psychotherapy · February 1995

DOI: 10.1176/appi.psychotherapy.1995.49.4.504 · Source: PubMed

CITATIONS READS
8 1,486

1 author:

Howard Book
University of Toronto
34 PUBLICATIONS   637 CITATIONS   

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Countertransference as a form of empathy. View project

All content following this page was uploaded by Howard Book on 24 April 2015.

The user has requested enhancement of the downloaded file.

 The "Erotic Transference": Some
Technical and Countertransferential
Difficulties

HOWARD E. BOOK, M.D., F.R.C.P.(C)*

This paper highlights dynamics that may interfere with the therapist's
identifying and addressing the erotic transference: (1) deficient training;
(2) theoretical orientations that devalue the transference while espousing
a "real" relationship including self-disclosure; (3) countertransference
responses to the erotic transference; and (4) clinical errors of focusing on
the manifest erotic transference while overlooking significant but latent
pre-oedipal, oedipal, aggressive, or self-object issues. Inattention to these
dynamics may render the therapist vulnerable to sexual acting out with his
patient.

This past decade has seen the recognition of a major ethical, professional problem
among psychotherapists: sexual exploitation by therapists of their patients.1,2 This
paper suggests that one dynamic that could lead to doctor-patient sexual acting
out, may be the therapist's mismanagement of the erotic transference. This paper
focuses on three related issues: (1) theoretical and technical problems in
identifying and managing the erotic transference; (2) latent meanings of the erotic
transference; and (3) some countertransferential issues in dealing with the erotic
transference. The therapist's inattention to these issues may encourage
inappropriate elaboration of the erotic transference and/or inappropriately encou-
rage the patient to act out sexually.
This paper is written from the perspective of a male therapist treating a
female patient in psychoanalytically oriented psychotherapy or psychoanalysis

*Associate Professor, Department of Psychiatry, Faculty of Medicine, University of Toronto;

Psychiatrist-in-Chief, Women's College Hospital, 76 Grenville, Street, Toronto, Ontario M5S 1B2

AMERICAN JOURNAL OF PSYCHOTHERAPY, VOL. 49, NO. 4, FALL 1995

504
The "Erotic Transference"
_________________________________________________________________

since most cases of exploitation involve a male therapist with a female patient.
The term "erotic transference" is defined as it is broadly and commonly
used in the psychoanalytic literature; any transference in which the patient's
fantasies contain elements that are primarily reverential, romantic, intimate,
sensual or sexual.3-5 Generally speaking, mismanaging the "erotic transference"
may have its roots in (1) the naïve therapist who is unable to identify, or actively
denies, the existence of the transference; (2) the therapist with counter-
transferential problems; (3) psychopathic therapists who are repeat offenders and
consciously prey on female patients; (4) the psychotic therapist who sexually
exploits patients because of delusional commands.
This paper will first address those therapists whose difficulty addressing
the erotic transference reflect theoretical and technical problems acknowledging
or understanding the transference itself. It will then focus on common counter-
transference problems that pressure the therapist to avoid or mismanage
addressing the erotic transference. These therapists fall into the first two
categories and constitute a large percentage of clinicians with difficulty dealing
with the erotic transference. Focusing on predator or psychotic therapists—those
in categories three and four—is beyond the scope of this paper. The final section
of this paper deals with difficulties that emerge from a lack of clarity about the
latent meanings of the erotic transference.

THEORETICAL AND TECHNICAL PROBLEMS CONCERNING THE

EROTIC TRANSFERENCE
Difficulties in recognizing and appropriately addressing the erotic
transference may speak to training deficiencies in psychodynamic psychotherapy
which reflect the current trivialization of psychotherapy in our residency
programs.6,7 Additionally, certain therapists bring with them a theoretical
orientation that devalues or denies the concept of transference, espousing instead
the patient's emotional growth through what has been termed an "authentic,
genuine, here-and-now relationship." 8,9 Therapy that relies on and promotes this
type of relationship often promotes what has been called "therapist self-
disclosure."8,9 In Sexual Intimacy between Therapists and Patients, Pope and
Bouhoutsos10 quote one disclosing therapist who, speaking of his
psychotherapeutic approach to a patient, states: "to help her overcome feelings of
isolation, I began sharing something of my own life, of difficulties I was having
with my wife." This self-disclosing therapist shows no awareness of boundary-
blurring that occurs through self-disclosing. It becomes unclear who is the
patient, who is the therapist, and who is to look after and gratify whom. Such a
situation may parentify and burden the patient, who unconsciously may feel
pressured to care for and protect the therapist.

505
AMERICAN JOURNAL OF PSYCHOTHERAPY
_______________________________________________________________________

In her paper, "Criteria for Therapist Self-disclosure," Simon9 notes that

therapists for whom self-disclosure plays a major therapeutic role: (1) tell about
themselves when and where they are asked, readily offering personal information;
(2) do not have a theoretical orientation that provides indications or
counterindications for such self-disclosure; (3) do not believe it is significant
whose material is being discussed; (4) do not value or acknowledge the
transference; (5) do not value self-awareness; (6) often hug a patient on leaving,
and consistent with their styles, make physical contact if they feel like it.
These concepts and activities blur the boundary between patient and
therapist and inappropriately encourage unnecessary intimacy. Furthermore,
these factors put both the therapist and patient at risk since the wishes and
fantasies are misinterpreted as reality, and may be acted on rather than understood
and resolved. This misinterpretation and interchange between fantasy and reality
easily sets the stage for exploitation of the patient for the therapist's
unacknowledged needs.
In his unpublished paper, "Patient-Therapist Sexual Contact: Harm to the
Patient", Richard Newman (personal communication) describes common themes
in eight women patients who sought treatment with him after being sexually
involved with their previous therapist. With all eight patients, each previous
therapist seemed to treat adoring feelings towards him as reality, instead of
accurately recognizing them as transferential. Similarly, all treated their patients'
complaints of the husbands as fact, without considering them as defensive
depreciation of that spouse. That is, all therapists overlooked and colluded with
the split transference, allowing rather than understanding the idealized
transference, and colluding with the defensive devaluation of the husband.
Perhaps as importantly, seven of the eight patients reported that the
therapist shared with them experiences in his own life; and that if difficulties the
patient had were similar, these would be compared and discussed. Again, this
represents a blurring of boundaries, with subsequent parentification and
exploitation of the patient by the therapist for his needs.
In all these cases, what seems significant is the therapist's unawareness of
the transference: his treating adoring feelings toward him and critical devaluations
of the husband as real rather than understanding them as being transferential.
Additionally, these therapists blur and ultimately violate boundaries by discussing
their own lives and problems. All these activities may encourage future boundary

506
The "Erotic Transference"
__________________________________________________________________

violations that may result in the therapist's acting out sexually with his patient.
Why is the transference not recognized as such? As I have alluded to,
possible because the therapist is naïve, with little training in understanding or
identifying the transference; or the therapist has countertransference difficulties
such as a need for an idealized self-object transference—as I will later describe.

COMMON COUNTERTRANSFERENTIAL DIFFICULTIES IN

DEALING WITH THE EROTIC TRANSFERENCE
There are factors other than the lack of training that may reflect why a
male therapist may allow, encourage, and even promote an acting out of erotic
transferences. These factors may reflect characterological problems within the
therapist. And one's first impulse may be to view all such therapists as
charismatic, manipulative, self-serving, psychopaths. Indeed, as the literature
suggests, some therapists are.11
However, to see all these therapists from such a perspective may be
understood as a defensive wish whose aim is to distance ourselves from these
people in order to reassure ourselves that we are very different from them. This
perspective denies that we may have sexualized wishes toward our patients, and
reflects our countertransference difficulties in separating wish from actions—
particularly in the realm of sexual desires.
Clearly, factors other than conscious manipulation, practiced exploitation,
or planned psychopathy may be involved when a therapist acts out sexually with
his patient. Rather, even a well-trained therapist, because of unique events in his
life, may experience a fragmentation in self-esteem or sense of self; and may
unconsciously exploit the gratifying idealization inherent in the erotic
transference to offset that fragmentation. That is, the therapist may be exploiting
the patient as a selfobject by encouraging mirroring or idealizing patient activities
in order to maintain his sense of inner stability. Understanding the unconscious
needs with which these therapists are wrestling is essential in aiding such
therapists, and preventing their patients from being exploited. It is in no way to
be confused with condoning their acting-out behavior.
In addition to the unique countertransferential difficulties a particular male
therapist may be experiencing, there exist general difficulties shared by all male
therapists that may lead to promoting an erotic transference. Lieber12 notes that a
developmental task common to all male therapists is the disidentification with the
mother; and that the vocation of psychotherapy carries within its nurturing
maternal style a regressive pull to that earlier disconcerting female identification.

507
AMERICAN JOURNAL OF PSYCHOTHERAPY
__________________________________________________________________

This regressive, anxiety-stimulating, female reidentification can be easily

countered by the promotion of an erotic transference that allows the therapist to
feel strongly experienced as male. The therapist who has character problems
relating to uncertainties about his own masculinity and potency, may
countertransferentially encourage the patient to respond to him in a highly
sexualized manner. Similarly, the therapist whose character style reflects
discomfort with dependent or clingy transferences, may also encourage
sexualization of what is primarily a pre-oedipal issue, and subsequently end up
focusing on the sexualization in order to avoid facing core issues of dependency
in his patient.

LATENT MEANINGS OF THE "EROTIC TRANSFERENCE"

This section focuses on difficulties that may arise in treatment, if the
therapist does not recognize the existence of latent meanings and functions of
what has been called the "erotic transference." That is, the erotic transference—
the existence of reverential, sensual, or sexual feelings toward the therapist may
represent significant but overlooked pre-oedipal issues, oedipal issues, hostile
issues, or selfobject issues that must be identified for treatment to be helpful.
The existence of these differing issues will be illustrated with a series of
vignettes.

OEDIPAL ISSUES
Even for a therapist who is able to identify his patient's adoring attitudes
as transferential, difficulties may occur because the therapist is not able to
recognize that the erotic transference may cloak another more germane but latent
transference. The following vignette illustrates some vicissitudes of the erotic
transference, and underlines how the erotic transference may signal the existence
of another disguised transference which must be identified and addressed:

Vignette 1
Early in therapy, after he returned from a one-week vacation break, Dr. X,
the therapist, was confronted by his patient, Ms. A, who said to him, "You would
like to have sex with me, wouldn't you? I would like that too. We want to have
sex with each other, don't we now?"
This confrontation was quite forward, with Ms. A looking Dr. X straight
in the eye as she continued: "I think you are more interested in that other patient
you see just before me, but I tell you, I can show you a better time sexually, any
night of the year. Even right now, here."
Please note that the manifest content is that of a patient wishing a sexual

508
The "Erotic Transference"
__________________________________________________________________

relationship with her therapist. Additionally, in this example, there is the

suggestion of her wanting to win his sexual favors over his previous patient.
As a result, even for a therapist aware of this striking transference, and not
taking her words at face value, there may be a temptation to view this as an
oedipal victory-wish, and to label this erotic transference as oedipal.
Consequently, the therapist might say something like: "It is sexually exciting for
you to think of taking me away from that other patient."
In making such a comment, this therapist, although aware of the
transference, would be overlooking the latent concerns hidden in this patient's
sexually provocative statements. His focusing only on the manifest wish would
be technically inaccurate and reflects a clinical imprecision in attending to subtle,
but significant clues concerning the patient's level of ego functioning, object
relationships, and early developmental difficulties.
For example, what is most striking in this clinical vignette is the blatant
and primitive quality of this woman's sexual wish. Her wish has an immediacy
and syntonicity without the embarrassment or disquietude that might be seen with
a purely oedipal transference. In addition, Ms. A does not speak about her strong
pressing wish as if it were a fantasy. It does not seem to be an experience she
wants to understand, but rather an experience she wishes to actualize. This
presentation more accurately reflects a fragility and enfeeblement of her
observing ego, which speaks to ego defects in reality testing, judgment, and
capabilities of maintaining distance from internal experiences. These are not
problems associated with oedipal issues, but rather address earlier pre-oedipal
problems in separation-individuation that have been secondarily sexualized.
Returning once more to Ms. A's words, we see more evidence of pre-
oedipal separation-individuation difficulties in her statement: "You would like to
have sex with me, wouldn't you? I would like that too." Ms. A seems unsure to
whom these sexual impulses belong. Are they the therapist's? Or are they hers?
Or do they belong to both? This uncertainty speaks to separation-individuation
difficulties in maintaining firm, consistent self-other boundaries. It also speaks to
her reliance on low-level defenses such as projection.
To confirm, the therapist might scan for a history of an overprotective,
nervous caretaker, worried about and uncomfortable over the patient's
independent development during her childhood.
One also might seek out hints of separation problems reflected in school
phobia or avoidance of summer camp. One must keep in mind, however, that the
description of such separation conflicts during early adulthood are often covered
by a history of acting out. Frequently, only the enjoyable partying, drinking, and

509
AMERICAN JOURNAL OF PSYCHOTHERAPY
__________________________________________________________________

sexual involvement are initially remembered. Only on closer examination are

these activities seen to be defensive, covering underlying separation-individuation
difficulties which are the core problem.11
For patients like Ms. A., clinically appropriate comments are not aimed at
her wish for sexual victory over other women, but ultimately voiced as: "You talk
as if my concern for you and your problems is waning"—or—"The idea that my
interest in you and your difficulties may be waning makes you feel quite uneasy."
This confrontation accurately focuses on the latent abandonment fears that are
hidden and cloaked by the manifest sensual wishes.

OEDIPAL ISSUES
In some patients, the erotic transference may reflect oedipal concerns.

Vignette 2
Ms. B showed her erotic concerns by stating: "I've been having thoughts
about you lately. They're kind of embarrassing to talk about. They make me feel
silly. They're quite personal. I am not sure why I am having them. They are kind
of, you know, physical, romantic. I don’t know what they mean."
In this scenario, the patient experiences these thoughts as fantasies, as
something to be explored. In addition, there is a sense of embarrassment, guilt,
and shame, that also speaks to their oedipal cast. Characterologically, there is
little evidence of primitive defenses, such as denial, projection, and splitting, that
would be seen in earlier, pre-oedipal situations. Additionally, one might expect
no history of difficulties in separation individuation, but rather a history of a
strong, exclusive relationship with the father. With this patient, interpretations
would take the form of comments such as: "You wish me to be involved with you
in a very passionate way that excludes anyone else—in the same way you
remember your relationship with your father during that time your mom was sick
in hospital."

AGGRESSIVE ISSUES
What seems to be an "erotic transference," may also cloak certain
significant aggressive issues, 13 as the following vignette illustrates:

Vignette 3
From the initial time she presented for evaluation, Ms. C presented in a
provocative, flirtatious and highly sexual manner. She would languidly cross and
uncross her legs, her mini-skirt slipping higher up her thigh; her crotch just barely
visible in the shadow of her skirt. She responded to the therapist's questions about
her psychosexual development with comments such as: "You seem awfully
interested in my sex life, doctor, and you seem a wee bit uptight about it. I notice

510
The "Erotic Transference"
__________________________________________________________________

that you use the "orgasm" instead of "come." Why is that?"

Although initially taken by her erotic presentation and flirtatiousness, as
he became more aware of his countertransference feelings of discomfort and
helplessness, this therapist began to focus on the covert, but hostile meanings of
her behavior. Ultimately, he was able to state accurately: "I sense that you are
getting a great deal of pleasure out of trying to make me uncomfortable." And:
"You seem to be quite gratified by toying with me." By empathically and
accurately focusing on this woman's aggressive wish to devalue, depreciate, and
control him, this therapist was ultimately able to understand more about her own
fears of being devalued and controlled in therapy. With this patient, it was the
latent hostility and its defensive functions that became the major therapeutic
focus. This vignette also illustrates the importance of the therapist's being attuned
to his own countertransference responses and attempting to use these in the
service of empathic understanding.14,15

SELF-ESTEEM AND SELF-COHESIVE ISSUES

Similarly, when viewed from a self-psychological perspective, what
appears to be an erotic transference may more accurately be understood as having
certain essential selfobject functions.16-18 These dynamics are illustrated in the
following vignette:

Vignette 4
Ms. D, a twenty-three year old, single woman, developed a strong erotic
attachment to her therapist. She said to him: "I wish you were free to marry me. I
wish it could be done. I really think that you are the kindest, most understanding,
warmest human being in the world. I keep having this idea that if we could be
married and be together my problems would be solved. I feel so good in your
presence. Just seeing you calms me down."
On many occasions, this therapist had viewed this sexualized idealization
as a defense against angry, envious feelings—but to no avail. Nor could he find
any evidence of the "return of the repressed" that would speak to such aggressive
impulses. Similarly, he could find no evidence of a split-transference: people in
this patient's life whom she saw in a devalued manner. Additionally, any time he
attempted to interpret these reverential feelings by commenting on the
hypothesized underlying aggression, Ms. D became more distraught.
Only by paying attention to how anxious and fragmented she became any
time he attempted to "interpret away" her reverential feelings, did this therapist

511
AMERICAN JOURNAL OF PSYCHOTHERAPY
__________________________________________________________________

become aware how this reverence fulfilled necessary idealized selfobject

functions that allowed her to feel cohesive and whole.
Here, the central issue spoke to this patient's difficulty in maintaining self-
cohesion and self-esteem. Her reverential view of him spoke of her need to align
herself with a highly idealized selfobject in whose presence she felt soothed,
calmed, and cohesive. Technically, it was important that the therapist not view
this transference as a resistance, nor to interpret it as a pre-oedipal wish, oedipal
need, or defense against hostility. Rather, what was clinically required of this
therapist was to allow the transference to unfold and note how shifts in this
woman's self-esteem or self-cohesiveness were linked to ruptures of the ideation.
And how, in addition, she gave a lifelong history of searching for idealized
selfobjects in order to maintain a sense of inner security. It was also important
that the therapist link empathic failures in treatment to her parents' inability to
provide such a climate for her during her growing-up years.

SUMMARY

This presentation has underlined the importance of the therapist's constant

attunement to sexual implications within the transference. Naïve therapists who
mistake the transference as a "real" response to them, personally; and therapists
who devalue the importance of transference while promoting self-disclosure, are
both at risk for burring boundaries between patient and therapist, and encouraging
inappropriate intimacy. Similarly, therapists experiencing fragmentation in self-
esteem or unconsciously wrestling with questions over their own potency may
attempt to promote an erotically idealizing transference. Therapists
uncomfortable with dependency issues may also inappropriately encourage and
focus on sexual issues in the transference. All these scenarios may lead to
antitherapeutic exploitation of the patient in the service of the therapist's
unacknowledged needs.
This paper also has emphasized the idea that the term "erotic transference"
may be confusing since it covers more specific latent transferences that speak to
oedipal, pre-oedipal, aggressive, or selfobject needs—each of which requires a
particular empathic, explorative, and interpretive focus.

REFERENCES

1. Kardener, S.H., Fuller, M., & Mensh, I.N. (1973). A survey of physicians' attitudes
and practices regarding erotic and non-erotic contact with patients. American
Journal of Psychiatry, 130, 1077-1081.
2. Gartrell, N., Herman, J., Olarte, et al. (1989). Prevalence of psychiatrist-patient
sexual contact. In G.O. Gabbard (Ed.), Sexual exploitation in professional
relationships, pp. 3-13. Washington, DC: American Psychiatric Press.

512
 The "Erotic Transference"
__________________________________________________________________

3. Fine, R. (1965). Erotic feelings in the psychotherapeutic relationship. The

Psychoanalytic Review, 52, 30-37.
4. Greenson, R.R. (1967). The Technique and Practice of Psychoanalysis. New York:
International Universities Press.
5. Frayn, D.H., & Silberfeld, M. (1986). Erotic transferences. Canadian Journal of
Psychiatry, 31, 323-327.
6. Reiser, M.F. (1988). Are psychiatric educators "losing the mind"? American
Journal of Psychiatry, 145, 148-153.
7. Gabbard, G.O. (1992). Psychodynamic psychiatry in the "decade of the brain".
American Journal of Psychiatry, 149, 991-998.
8. Weiner, M.F. (1978). Therapist disclosure. Baltimore, MD: University Park Press.
9. Simon, J.C. (1988). Criteria for therapist self-disclosure. American Journal of
Psychotherapy, 42, 404-415.
10. Pope, K.S., & Bouhoutsos, J.C. (1988). Sexual intimacy between therapists and
patients. New York: Praeger.
11. Twemlow, S.W., & Gabbard, G.O. (1989). The lovesick therapist. In G.O. Gabbard
(Ed.), Sexual exploitation in professional relationships, pp. 71-87. Washington DC:
American Psychiatric Press.
12. Liebert, R.S. (1986). Transference and countertransference issues in the treatment of
women by a male analyst. In H.C. Meyers (Ed.), Between analyst & patient, pp. 229-
236. Hillsdale, NJ: The Analytic Press.
13. Kernberg, O.F. (1975). Borderline conditions and pathological narcissism. New
York: Jason Aronson, Inc.
14. Book, H.E. (1987). The resident's countertransferernce: Approaching an avoided
topic. American Journal of Psychiatry, 41, 555-562.
15. Book, H.E. (1988). Empathy: Misconceptions and misuses in psychotherapy.
American Journal of Psychiatry, 145, 420-424.
16. Kohut, H. (1977). The restoration of the self. New York: International Universities
Press.
17. Baker, H.S., & Baker, M.N. (1987). Heinz Kohut's self psychology: An overview.
American Journal of Psychiatry, 144, 1-9.
18. Rowe, C.E., & MacIsaac, D.S. (1989). Empathic attunement. Northvale, NJ: Jason
Aronson Inc.

513

View publication stats