Countertransference to Sexual and Developmental Trauma in the Psychoanalysis of a Disabled Patient

• Our First Meeting
• Being a Sexual Person
• Homosexual Feelings
• Fear of Driving Me Away
• Transference and Countertransference
• Final Thoughts

Our First Meeting

Referred to me by a colleague, Tanya was an elementary school principal who had polio as a child. When I initially asked my colleague how severely Tanya had been affected, she told me, “It isn’t too bad.” When I opened the door to my waiting room to greet my new client for the first time, I was shocked to see that Tanya had a deformed arm and leg. She struggled to get out of the chair and when she stood up, I was struck by the contrast between my colleague’s description and the reality before me. I wondered what made my esteemed colleague deny the severity of Tanya’s deformity.

Tanya settled into the chair in my office and was silent. Although she was in her late thirties and a successful professional, she was dressed like a pre-adolescent in short white socks and sneakers. When I asked what brought her for psychotherapy, she said she wanted to feel sexual.

“Everyone else has somebody,” she said. “They have a husband, they have children. I have nothing. I hate my life. I need something, help me, help me,” she cried. “I need something. I want someone to love me. I want to get married. I want a family."

In her third session, Tanya began talking about her deformity.

“Nobody can see it,” she said. “Nobody knows I had polio, that’s why nobody says anything about it. You can’t tell, can you? Can you?”

Shocked that she could be in such a state of denial, I hesitated a moment.

“Yes,” I said as softly as I could, “I can tell you had polio.”

“I’m sorry. How can you say that?” she yelled. “You’re horrible. I’m sorry. I’m not coming back.” She hugged her purse but did not leave.

Tanya’s pleading for me to deny her deformity and the repetition of “I’m sorry” continued for many months. It grated on me. I wanted to yell at her: “Stop it, I can’t stand it.” Session after session as the same scene unfolded over and over, I felt tortured by her, and I felt guilty for feeling tortured.

“I think my mother couldn’t stand me,” she said. “She wanted me to go away.”

Finally, to my great relief, I realized that this was an enactment of her experience with her mother.

When Tanya was ten, she complained that she had intense back and neck pain, but her mother told her “it was nothing” and to go to sleep. But Tanya could not sleep. Finally, when she was in such pain that she couldn’t walk, her parents took her to a doctor, who said she had polio and needed to be hospitalized immediately. Her parents did not explain it to her. The doctors explained it to her parents, but not to her. She did not understand that she would have to remain in the hospital for several weeks. Her parents did not visit every day because the hospital was far from their house, and when they did visit, they only stayed for an hour. Tanya was filled with anxiety and rage.

When she was finally released from the hospital, recuperating at home, Tanya often pleaded for her parents to tell her she would not have to go back to the hospital. Her parents said, “No, don’t worry.” They knew that was not true, but they could not bear her reaction to the truth. When she had to go back a second time, she was enraged that her parents had lied to her.

Tanya felt betrayed and unprotected. Her parents said they would visit and didn’t come; they said she would be fine, and she wasn’t. After a while she felt that she could not trust anything they said. Later, when she went through puberty and the curvature of her spine worsened, her mother assured her that no one could tell she had had polio.

I knew that telling Tanya that I could see her deformity would enrage her. But if I had tried to avoid it when she communicated “Don’t you dare say you can see it,” I would have communicated that I was unable to deal with the reality of her polio—just like her mother.

Nevertheless, I continued to feel I was between a rock and a hard place with Tanya. I did not want to lie to her as her mother had, but telling her the truth enraged her.

“Do you think I’ll get married?” she pleaded over and over.

I felt a wave of meanness. The lyrics to “Que Sera Sera” came into my head:

“When I was just a little girl
I asked my mother
What will I be
Will I be pretty
Will I be rich
Here's what she said to me.”

I knew any answer other than “yes” would result in her fury and threats to quit treatment.

“I cannot predict the future,” I said. “I don’t know if you will get married.”

“You’re horrible,” she yelled, picking up her purse from the floor and embracing it. “How can you say that to me? I’m sorry. What’s wrong with you? I’m sorry. I’m not going to come back anymore…”

“What would you like me to say to you?” I asked. My head throbbed.

“That I’m going to get married like everyone else. What’s wrong with you?” she yelled.

“Do you want to get married?” I asked.

“Of course, I want to get married. But who will want to marry me?” she cried.

I could hear my heart thumping. What am I going to say to her? She was right to feel her chances were diminished because of her disability.

“You’re right,” I said. “There are some men who will not be interested in you because you had polio. But there are some men who don’t have perfect bodies either or who are more interested in finding someone who they can feel close to than whether her body is perfect.”

She was quiet.

“You had polio, and it affected your arm and your leg,” I said. “That is part of who you are, but that is not all that you are.”

Tanya had not been able to accept that she had polio and tried to cope with it by joining in her mother’s denial that it was visible. I realized that my referring colleague had also been drawn into the denial.

Being a Sexual Person

As the treatment deepened, it became clear that Tanya’s overwhelming anxiety was not simply the result of her polio. One session was a turning point in our understanding Tanya’s level of anxiety and confusion. She began by talking about seeing her doctor for dizziness.

“I went to see Dr. Roberts, and he took my blood pressure,” she said. “It was lower than it has been since this whole thing began. But then he took it ten minutes later and it went up. But it still wasn't as high as it has been in the last few weeks.”

Tanya sat with her legs spread apart. Her crotch was in full view. She did this often when she was wearing a skirt. I was trying not to look at her crotch while she was talking to me, but I thought she was not wearing underpants. I thought to myself that perhaps she was just wearing dark underpants. At first, I questioned whether I was imagining things, but I knew what I was seeing. I started thinking about how to handle it. If I ignored that she seemed to be exposing herself to me, I would be denying the reality. On the other hand, I knew that however I said it to her, she would be mortified and furious at me if I brought it up. In the past I felt the mortification would be too much for her, but this time I felt I could not ignore it.

“Are you aware of how you're sitting?” I asked.

Tanya immediately put her knees together.

“What are you talking about? What are you saying? I'm sorry. You hate me. You think I'm bad. What are you saying? You want me to leave?”

“I don't hate you,” I said. “I don't want you to leave. You were sitting with your crotch exposed to me, and I think that has some meaning. Don’t you?”

“I'm sorry. I like you and I respect you. I don't know what you're saying,” she cried. “You think I'm bad. I'm sorry. You want me to leave.”

“I know you like me and respect me, and I don't want you to leave,” I said. I leaned forward in my chair. “I don't think you are bad. You don't need to apologize. I just think that sitting like that means you have some feelings about yourself and about me that we need to understand.”

“I'm sorry. Sitting like that doesn't mean anything. I just don't think it matters how I sit.”

“You mean it doesn't matter if your crotch is exposed or not?” I asked.

“I just don't feel like a sexual person. I don't feel like a woman. Look how I dress. Look how I take care of myself. I just don't feel like a sexual person; that's why it doesn't matter how I sit.”

“You mean you feel like there's nothing between your legs?”

“That's right. What's between my legs is dirty and smelly and bad and disgusting. You don't want to see it.”

“So you think that I am pointing out how you're sitting,” I said, “because I feel your vagina is bad and smelly and disgusting.”

“I offended you. I'm sorry. I won’t do it again. Don’t worry about it.”

“You didn't offend me. But I think exposing yourself is a way of telling me something.”

“You know, you're really inappropriate sometimes. I can't believe you said that to me. Who would say such a thing? I don't know anyone who would say such a thing.”

“You mean you would rather I act like your mother and make believe that there's nothing between your legs or that it's too disgusting to talk about?”

“Maybe it's like the polio. I don't want you to see that I have it. I want you to say you can't tell I have it. But I also don't think I have anything. I am completely out of touch with my body,” she said, crying. “I don't feel connected to it. I can't touch myself still. I don't feel like a woman. Even now with the operation, I still don't really have breasts. Sometimes I don't even bother to wear a bra.”

“What about underpants?”

“What do you think is wrong with me? Do you think I don't wear underpants? Of course I wear underpants.”

“If you don't feel you need to wear a bra because you don't feel you have breasts, I wondered if you don’t wear underpants because you feel you don't have a vagina or clitoris."

“Of course I wear underpants, what do you think is wrong with me?” she yelled. “How could you say that. I can’t believe it. You must think I’m disgusting.”

She got up and walked out of the office. I was not sure she would come back.

When Tanya did come back for the next session, she was angry for the first few minutes. But then she told me that after the session she remembered her mother sitting in the living room on the couch with her legs spread and touching herself.

“You mean your mother was masturbating in front of you?” I asked.

“Yes. She did it in front of my brother too. I wasn’t sure what she was doing. I asked her to stop, but she said she wasn’t doing anything.”

Tanya explained it was like listening to her older brother masturbate. She told her mother that her brother was making strange noises and she didn’t want to share the same room with him, and her mother told her it was nothing and she should just go back to bed. Tanya grew up in a dark, one-bedroom apartment. Her parents slept in the living room, and she and her older brother shared the bedroom. Her parents could have afforded a larger apartment and were even offered one for modest cost in the same building, but her mother did not want to move.

Her mother and brother overstimulated Tanya, and her mother’s denial gave Tanya no protection from the anxiety created by it. Tanya was forced to develop other ways of coping—being confused, not knowing if she was hearing things or not. Her anxiety was so overwhelming it interfered with her thought processes and her reality testing. Years passed in therapy before Tanya brought in a dream she identified as sexual.

“My car was damaged, someone hit it and the door and fender were all bent. I looked underneath, and it was perfect. I felt surprised and happy.”

“When did you have the dream?” I asked.

“I had the dream after our last session. I think it’s about myself. I am finally accepting that I am damaged on the outside, but I am all right inside.”

“Yes, it sounds like a positive dream. What comes to mind about looking underneath?”

“It was underneath the hood. Inside. But it sounds sexual doesn’t it? Maybe I realize that I am damaged outside, but I am not damaged sexually.”

“And you're surprised?” I chuckled.

“Yes, I have always been afraid of sex. Something is wrong with me. When I go to the gynecologist, she can’t even examine me.”

“Because you are so frightened that you have a spasm?” I asked.

“Yes,” she said. “I have always been terrified of touching myself or someone touching me. I’m terrified. I just see a man with a suit eating pizza and I think he’s cute and I feel terrified.”

“I think you have sexual feelings,” I said, “and then imagine he wants to have sex with you right there in the pizza store and then you are terrified.”

“Yes, I only feel the terror, but I must be having sexual feelings,” she said.

“I think you become overwhelmed by your sexual excitement and project it onto the other person and then feel terror. You know when you would lie in bed listening to your brother masturbating and coming, that was overstimulating. You knew it and went to your mother, but she denied the whole thing and told you to go back to your room. You couldn’t get any help protecting yourself from the overstimulation.”

“It was normal for him to masturbate. I know kids masturbate, but I shouldn’t have been in the same room. I should have had my own room, and when she just told me to go back to bed and ignore it, I must have felt flooded.”

“Exactly,” I agreed.

“You know, she said, “I had another dream last night. “I was watching somebody teach somebody how to dance. This young girl was very graceful, and she was moving very well. She knew how to dance. They were getting ready for a wedding.”

“How did you feel in the dream?”

“I felt good,” she chuckled. “I felt I could learn to dance. You know, they had dancing at my beach club on July 4th, and I didn’t dance. But next week, they’re having a DJ and they are doing line dancing, and I’m going to get up and learn how to do it. I’m going to join in.”

The following session, Tanya came in saying she had a dream about tongue kissing the night after the last session.

“I was eating dog food, and my mother was telling me I was eating dog food. I was licking the bowl like a dog and I got nauseated after she said that, and I threw up in the dream and, in my bed. I was gagging and choking.”

“What comes to mind about dog food?”

“Dogs go right for sexual gratification, they’re animals. They can’t delay gratification. Maybe I’m the one who’s bad because my mother tongue-kissed me in my dream. I was acting like a dog.”

“Maybe we're acting like a good dog—a loyal dog does whatever the master wants,” I said.

“Dog food looks like shit. I was eating shit. All my life I was eating shit. I was an obedient dog. Every day I was choking and gagging before I went to school. In the dream I said, ‘I must get it out of me.’ Something was stuck in my throat. It’s a feeling of fear. You know, my brother can’t swallow pills; he gags also.”

“Really!?”

“What could be stuck in my throat? Do you think this is at the bottom of why I can’t touch myself or have sex?” she asked.

“Yes, I think that your mother was crazy, and she masturbated in front of you and acted like nothing was happening and kissed you sexually and acted like it was normal. When you told her your brother was masturbating and you didn’t want to share a room with him, she said it was nothing and you should forget it. I think this is only the tip of the iceberg. I think there’s a lot you haven’t been able to tell me yet. Maybe you’re afraid I’ll think you’re bad.”

“Yes, I think so. You know, she would sit with her legs spread apart and pull her underpants to the side and play with herself. She did it while we were watching TV. My father was there sometimes, and he never said anything. My brother was there. If I asked her to stop, she would ignore me.”

Homosexual Feelings

Tanya was angry because I did not hear the doorbell—she had to ring twice, and the clock in my waiting room was four minutes fast. Anything that questioned reality (e.g., what time is the session) threw her into questioning everything. I also thought it might make her feel that I was out of control or her feelings toward me could get out of control. Maybe she felt I was like her mother if the time was wrong and I didn’t hear her. It threw her into a panic attack and made her question reality.

The next session, Tanya came in saying that she was upset and sad after our last session. It might have been from talking about how sexually stimulating her house was and that she might have felt aroused by it, or it might have been about my clock being wrong. She said the erroneous clock made her feel crazy. Then she moved on to talk about being angry at a teacher with whom she worked. She thought he was gay but that he could not deal with it because he was religious. Then she talked about being angry at her friend’s husband, who always talked about women he wanted to screw. Tanya thought it was a defense against his homosexual feelings.

“It’s interesting that in both cases you’re angry at people who are denying their homosexual feelings,” I said.

“Do you think I’m homosexual?”

“No,” I said, “but I think you might be afraid that you have sexual feelings about me.”

“That would be inappropriate, wouldn’t it?”

“No, I don’t think feelings are appropriate or inappropriate—they just are what they are. We don’t have control over our feelings, only our actions. Considering your mother’s sexually provocative behavior toward you, I don’t think it would be surprising if you had sexual feelings about me.”

“How would you feel if I had sexual feelings toward you?” she asked.

“I would feel happy for you that you were able to be in touch with your sexual feelings, whatever they are. You haven’t been able to experience them at all.”

“After the last session I had this tension in my inner thighs. Do you think that was a sexual feeling?” she asked.

“Yes, I think that was sexual tension.”

“How do you get rid of sexual tension?” she asked.

“Well,” I said, “you could masturbate or have sex with someone else. Sexual tension gets built up and then released when you have an orgasm.”

“I have to get a Pap smear on Wednesday. I’m afraid I won’t be able to do it. I feel like canceling it.”

“Are you afraid of having sexual feelings during the exam?” I asked.

“Yes, what if I have sexual feelings during the exam? What should I do?”

“You don’t have to do anything. You can just have them, and eventually it will pass.”

“Oh,” she said, seeming relieved.

Fear of Driving Me Away

Tanya walked into my office and sat down clutching her purse on her lap.

“I couldn't find a parking spot. It's getting harder and harder to find a spot around here. It makes me so frustrated,” Tanya said.

“What about that?” I asked.

“It makes me feel so annoyed and angry.”

“Maybe you're annoyed and angry at me?”

“No, I just can't stand how hard it is with all the traffic and it's so hard to find a spot. It makes me not want to come.”

“Maybe you had some feelings about coming today?” I asked.

“I was thinking about stopping,” she cried. I have too many feelings about you. I'm sorry, my feelings are too strong...”

“What are you sorry about?” I asked.

“You don't want me, you wish I'd go away,” she said angrily.

“What is it about you that makes me want you to go away?”

“I'm sorry, I have too many feelings about you.” She picked up her purse and hugged it.

“You mean I can't stand your feelings about me?”

“I'm sorry. I want too much; you won't want to give it and you'll want me to go away.” Tears flowed down her cheeks.

“Why would your feelings be so intolerable to me?”

“I want to talk to you all the time. I'm sorry.”

“If you want to talk to me all the time, do I have to do it?” I asked. “Why can't you want whatever you want?”

Tanya looked surprised. “Because I want you to do it!”

“If I felt I had to do whatever you want, I wouldn't be able to stand your feelings. But I don't feel I have to do things just because you want them, so I can allow you to want whatever you want.”

“I don't think my mother could stand my feelings,” she whimpered.

“No,” I agreed, “because she felt she had to do something about them and she couldn’t, so she wanted you to go away.”

Transference and Countertransference

Tanya’s transference changed during various times in the treatment. At the beginning, she experienced me as if I were her mother who wanted her to go away. But this was not a neurotic transference onto me; rather, she induced in me the feelings her mother had about her. She pleaded for me to lie to her but wanted to believe me. She wanted me to feel what her mother had felt but be a better mother than hers had been. It was a struggle for me; I felt harassed by her pleading and guilty for not feeling empathic. I found it difficult to bear her pain and her rage at the hand she had been dealt. Her demands for reassurance made me feel helpless, which is probably how her mother felt. I had to find a way to help her accept reality but also console her.

Later in the treatment, when she was finally able to deal with her sexual feelings, the transference shifted. She was not able to tell me what had occurred with her mother. Rather, she created an enactment of it so that I would understand what she had felt as a girl. I became confused about reality just as she had—e.g., is she wearing underpants?

Final Thoughts

Tanya would remain in treatment with me for over ten years. When she terminated, she was a much more integrated person. She felt like a sexual woman and got over her social phobia enough to develop close friendships with both men and women. Tanya was able to accept the gaslighting, denial, and lack of boundaries in her family. She became closer to her brother and convinced him to seek treatment.

Of course, there were many other issues in her treatment that I have not dealt with in this article—e.g., her envy of me for not having a misshapen arm and leg. I have only highlighted the issues of denial of her disability and the lack of boundaries and sexual overstimulation in her family.

I think it was important that I told Tanya her disability was visible for two reasons. First, she knew that it was. If I denied it, it would imply that it was so horrible that I couldn’t deal with it. I would be like her mother – distorting reality because I could not tolerate Tanya’s pain. Second, Tanya did not trust her parents because they consistently lied to her. She called me constantly to confirm our appointments. And when applying for a handicapped license and being told she would have to wait 60 days, she called them daily to confirm it. So I had to be truthful to build her trust, even though it enraged her.

Some therapists might have avoided confronting Tanya about exposing herself to me. It was awkward and uncomfortable for me, and it enraged her. However, I think it was a major turning point in the treatment. As a result, she was able to tell me about her mother’s exhibitionism; she became more able to identify and process her own sexual feelings, which reduced her projection of them onto men. She also made progress in being able to comfort herself.

Although Tanya was not able to have a sexual relationship with a man, she bought a dog and named him “Sigmund” as a testimony to how much psychoanalysis had helped her. She did the macarena with the husband of her friend and felt sexually aroused. She understood that her sense of sexual abnormality had more to do with her mother than polio.She also made progress in being able to find comfort. Although she was not able to have a sexual relationship with a man, she was finally willing and able to treat herself to massages regularly and was able to masturbate. Overall, Tanya had come a long way. Her social and sexual anxieties were greatly diminished and she had a much more fully developed sense of self. It was very hard work for Tanya, and in a different sense, for me as well. 

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