How To Work Through Erotic Transference

While some people take it for granted that patients fall in love with their therapists, the fact that patients do so with some regularity is astonishing. Of course, therapists call these feelings transference, but the patient often experiences them as genuine feelings of love and longing. Furthermore, therapists besotted with love for a patient often think their own reactions are far more than mere countertransference.

Sigmund Freud was the first to describe the phenomenon of the erotic transference, theorize its origins, and make a connection between transference and romantic love. But an understanding of the erotic transference did not spring full-blown, even to Freud. His introduction to the phenomenon began with a strange series of events that he learned about through his mentor and collaborator Josef Breuer.

The talking cure was an early precursor of psychoanalysis and developed in the course of Breuer's therapy with "Anna O," a woman with many hysterical symptoms. She initiated a free association, in which speaking of the origins of each symptom caused it to disappear. She called this process "chimney sweeping." Breuer, who was fascinated with Anna O's treatment, was thought to have ignored his wife and thereby provoked her jealousy. Chagrined, he terminated Anna O's treatment. Shortly afterward, he was called back to find her in the throes of a hysterical childbirth. He calmed her down, but the next day he left to take his wife on a second honeymoon.

Freud reported these events in a letter to his wife, Martha. In The Life and Work of Sigmund Freud (1953-1957, Basic Books) Ernest Jones, M.D., noted that Martha identified with Breuer's wife and hoped the same thing would not happen to her. Freud reproved her vanity in supposing that other women would fall in love with her husband; for that to happen, he would have had to be Breuer. Only later did Freud come to see Anna O's reaction as the rule, rather than the exception.

It was not easy for Freud to arrive at insight into the erotic transference. Simply being a close colleague seems to have brought him too close to the phenomenon for comfort. Freud's reluctance in recognizing the phenomena may be some measure of the power and threat that erotic transference exerts even to this day.

Ultimately, Freud's understanding of the phenomenon of transference love deepened in response to his growing knowledge of other such transferences. He was privy to several instances of enacted patient-doctor affairs. For example, at a time when Carl Jung was still a disciple of Freud, Jung fell in love and began a relationship with one of his patients, Sabina Spielrein. This was well-known to Freud because Spielrein fled Jung to go into treatment with Freud.

Freud formulated the dynamics of the erotic transference as re-enactments of a patient's early life impulses and fantasies that emerge during the process of analysis and that replace a protagonist from the patient's past life with the person of the therapist. At first, he placed more emphasis on the repetition inherent in transference and not on its subjective reality for the patient, having not yet distinguished the dramatic difference between the way the patient experienced transference and the way the psychoanalyst viewed it.

Over time, Freud formulated a theory about the relationship between the erotic transference and the experience of love, recognizing that feelings of love, whether in treatment or in real life, draw on earlier life experiences. Researchers of infant behavior and attachment theorists have demonstrated a rather dazzling, virtually identical counterpoint between certain behaviors of mother-infant dyads and lovers. Daniel Stern, M.D., for example, described similar behaviors such as maintaining very close proximity and performing special gestures, such as kissing, hugging and touching. The physical and emotional language of love begins in earliest life, and one of its developmental end-products in our culture is romantic love or--in the treatment situation--the erotic transference.

While the erotic transference and countertransference were first identified in the context of a male therapist and a female patient, there are four primary kinds of transference situations: heterosexual women in treatment with heterosexual male therapists, heterosexual men in treatment with heterosexual female therapists, homosexual men in treatment with homosexual male therapists and homosexual women with homosexual female therapists. The latter two constellations have only recently received attention.

It is still probably true that the erotic transference is more overt in heterosexual women in treatment with heterosexual male therapists than in the reverse situation. What are the reasons for this sex difference and its consequences, if any? Merton M. Gill, M.D., suggested a distinction between transference resis-tance and resistance to awareness of the transference. The erotic transference utilized as resistance is more common among women in analysis--particularly among women in treatment with men--while resistance to the awareness of the erotic transference is more common among male patients.

This is not always the case, however. One of the more famous cases in which a patient married the therapist took place between the analyst Frieda Fromm Reichmann, M.D., and her patient Erich Fromm, Ph.D., both of whom were towering figures in psychoanalysis. Given their example, it might be argued that transference love and authentic love are not necessarily mutually exclusive.

Transference and countertransference are, by their nature, complex and interrelated. However, they cannot be understood solely within a model of attachment and its re-enactment. Power dynamics in interpersonal relationships also play a role. In addition to reviving early erotic attachments to one or another family member, the erotic transference is fueled by wishes for egalitarianism, if not for achieving the power position. Love, after all, serves to equalize power between lovers. Thus, the act of falling in love is connected to power dynamics. Freud recognized that women sometimes used the transference in an attempt to compromise the physician's authority. Freud's insights--and later, Gill's--that transference love may be used as resistance show how it acts as an attempt to exert control over the situation. It is an example of power-seeking, if you will.

The erotic transference sometimes mirrors a young person's struggle to attain parity in the power position as they emerge into adolescence, often by partnering with someone more prestigious--the quarterback, the cheerleader or the class brain. Despite the contemporary attempt among many therapists to achieve a more egalitarian relationship in the therapy situation, the patient generally perceives it in hierarchical terms. Power can be expressed through what I call weak power; for example, a patient seducing a therapist with appreciation, flattery and admiration. Analogously, therapists may seduce their patients through the awe their position affords them and through what passes for strength. These strategies are more often preconscious than conscious.

Compared with other transferences, the erotic transference has always been tainted by unsavory associations and continues to be thought of as slightly disreputable. However, we should not lose sight of the fact that it may confer on the patient a new appreciation of the possibilities inherent in relationships (sometimes through an identification with a therapist's empathy and kindness). The therapeutic usefulness of the erotic transference is twofold: the wealth of psychological material it yields in understanding both erotic and power issues and the strength of the emotional charge that initially sustains the patient through some hard work. However, to the degree that it persists, it becomes a limitation in the analysis.

Consider the following vignette: A psychiatrist asked me to see one of his patients, a woman in her 30s who was stalled in an erotic transference that had become sufficiently intense that it was interfering with their work. The woman was in a marriage that had appeared satisfactory in its early years. The daughter of a successful entrepreneur, favored by her father and rejected by her mother, she had eschewed any potential partner who reminded her of her beloved but overbearing father. Instead, she had married a loving man whom she could dominate, but she lost respect for him when he failed as a businessman. She balanced her life by sexualizing her work relationships and was thus able to make an adaptation that seemed good enough. Her compromised marriage also resonated with her retreat from her childhood Oedipal victory. Such a precarious balancing act was shattered at the onset of a family crisis, during which her husband was unable to give her what she thought was adequate support, and, thus, she entered therapy.

In the acute phases of her difficulties, her psychiatrist was extremely helpful, but his very competence activated desires long suppressed in her. Because of a rapidly escalating erotic transference, he sent her to me for consultation. She was ambivalent as to whether she wanted a relationship with her psychiatrist or whether her feelings for him were a wake-up call that she wanted a different kind of relationship.

In treatment, she had become aware of the possibility of a more intimate kind of communication and responsiveness. In the consultation, she concluded that her psychiatrist could help her achieve a fuller relationship with her husband or someone else, but not with him. She and her psychoanalyst subsequently worked through her erotic transference. In part, she came to forgive her husband for failing to provide her with vicarious power. Like this patient, a number of women feel that their femininity can be endorsed only by a powerful man--a mindset that conceals an inhibition in establishing their own agency.

In men who are in treatment with women, one more often sees resistance to erotic transference, rather than full-blown erotic transference itself. This may be enacted outside the transference relationship. One of my patients, a married man, entered into a transient extramarital affair. He told me that he had seen me on television, but not the whole interview because he was in bed with his girlfriend and they began to have sex. Interpreting such manifestations of a displaced erotic transference generally evokes resistance, but can ultimately prove effective. It should be noted, however, that the erotic transference as resistance occurs in men as well as in women and the resistance to the transference in women as well as in men. Moreover, each of the different therapy permutations--gender and sexual orientation of a patient and therapist--has special wrinkles that are beyond the scope of this brief article.

The patient's erotic transference, whether enacted within or outside treatment, disguises a number of disparate and contradictory transferential strategies and aims. The erotic transference is always layered: it is composed of different strands, not all of which are erotic. We miss its complex dynamics if we fail to look at the hidden yearnings for asserting power or claiming protection for weakness.

Over time, the psychoanalytic view of transference has enlarged. The patient's capacity to form a transference relationship to the therapist is a key factor in facilitating change. Developing, recognizing and working through an erotic transference are often central to the psychotherapeutic process.