[PSYCHOTHERAPY ROUNDS] Series Editor: Paulette Marie Gillig, MD, PhD

RECOGNIZING AND MANAGING EROTIC

AND EROTICIZED TRANSFERENCES
by DARNELL LADSON, DO; and RANDON WELTON, MD, LtCol, USAF

Drs. Ladson, Welton, and Gillig are from the Department of Psychiatry, Wright State University, Dayton, Ohio.

ABSTRACT
Transference has been proposed
as a critical concept in
psychotherapy. The transference
may be positive, negative, or
sexualized. When the transference
becomes sexualized, there are
potentially damaging outcomes
depending on the management of
the transference. This paper
addresses the significance of early
experiences in residency training
with sexualized transference and
focuses on the therapeutic
relationship in which the
transference has become eroticized.
The author will explore the
potential benefits and challenges of
properly managing such
transference.

INTRODUCTION
Transference has been described
as unconscious feelings that are
transposed onto another significant
individual.1 In the strictest sense,
this occurs only in therapy settings,
but in a more general sense it
occurs throughout life. The
experience of transference might be
thought of as a means used by the
brain to make sense of current
experience by seeing the past in the
present and limiting the input of
new information.2 Freud noticed the
unusually and sometimes ADDRESS CORRESPONDENCE TO: Darnell Ladson, DO, Department of Psychiatry, Wright State
irrationally intense feelings that University, 627 Edwin C. Moses Blvd., East Medical Plaza, First Floor, Dayton, OH 45408; Phone:
developed between patients and (937) 223-8840; E-mail: darnell.ladson@wright.edu
their analysts. He initially
conceptualized the transference as KEY WORDS: psychotherapy, countertransference, transference, sexualized transference, erotic
the patient’s attempt to repress transference, eroticized transference

[APRIL] Psychiatry 2007 47

childhood experiences. Later he material and gain a deeper process are often left
observed that feelings of love not understanding of the patient’s uninterpreted. It can be a technical
only occurred in the past outside motivations.5 Contemporary challenge to address transference
the therapy session, but also during analysts contend, as their in therapy, because raising
the analysis itself toward the predecessors once did, that erotic awareness to the transference can
analyst.3 transference reflects a patient’s stress the patient, leading to
Sexualized transference is any early life impulses and fantasies regression or awkward and
transference in which the patient’s that emerge during the process of embarrassing moments in therapy.
fantasies about the analyst contain analysis. The acknowledgment of
elements that are primarily transference feelings, if sexual, may
reverential, romantic, intimate, TYPES OF TRANSFERENCE be mistaken as an invitation for
sensual, or sexual.4 As early as In general, transference may further flirtation or a sexual
1915, Freud addressed this manifest itself as positive, negative, relationship. This could lead to the
phenomenon in his paper, or sexualized. In positive collapse of the safe environment the
“Observation on Transference transference, the patient therapist has struggled to create.6 It
Love.”3 He described transference experiences enjoyable aspects of is of course unethical to use the
love as occurring when the patient past relationships. Positive discussion of the intense feelings
openly announces love for the transferences are often helpful in involved in the transference for a
therapist. therapy if the patient sees the therapist’s own self-gratification,
At the time Freud wrote about therapist as wise, caring, and and this is to be avoided.
“transference love,” the field of concerned.
psychoanalysis was under attack by Negative transference COUNTERTRANSFERENCE:
the public. Some of these attacks unleashes emotions that are painful BOUNDARY ISSUES FOR
centered on reports of sexual or less desired. By discussing these PSYCHOTHERAPISTS
experiences between analysts and negative emotions with the patient, The intense emotional
their patients. Freud struggled with the therapist hopes to help the experience of countertransference
whether transference came from patient achieve insight and to find in psychotherapy also is not rare.
the real relationship between the ways to manage these feelings. Some studies have reported that 95
patient and therapist or if it was Positive and negative percent of male therapists and 76
entirely unreal (i.e., displaced transference can become topics for percent of female therapists admit
feelings from other relationships). discussion in therapy. The patient that they felt sexual feelings toward
Today there are ongoing is encouraged to acknowledge and their patients.6 Identifying and
discussions in the literature about discuss emotional responses to the therapeutically managing one’s own
the nature and role of transference. therapist, especially if they seem intense feelings is one of the on-
The transference relationship is out of proportion to what has going challenges of
complex and multilayered while actually transpired in the session psychodynamically based
psychotherapy. These challenges
are enhanced in the novice
Positive and negative transference can become therapist who may have little
training in these issues and virtually
topics for discussion in therapy. The patient is no experience with them.

encouraged to acknowledge and discuss PRACTICE POINT: Family of

Origin Issues and Potential for
emotional responses to the therapist, especially Transference in the Therapeutic
if they seem out of proportion to what has Relationship
Case example. A middle-aged
actually transpired in the session itself. woman describes her childhood
as being filled with rage. She
attributes this to her emotionally
being significantly impacted by itself. This allows patients to make abusive father and sexually
countertransferential reactions. connections between what they are abusive brother. She states that in
The therapist has become less of a feeling in the room with their order to enhance her sense of
“blank screen” and more therapist and their early life safety, she developed techniques
interactive with the patient and, experiences, and this enables to control and manipulate her
therefore, a part of the developing development and growth. father.
transference. Transference may be Transference situations that are In psychotherapy with a male
utilized to gather psychological not interfering with the therapeutic therapist, a patient might display

48 Psychiatry 2007 [ A P R I L ]
behavior that is reminiscent of early intense, vivid, irrational erotic boundaries between them. For
childhood relationships. A female preoccupation with the therapist many psychiatric patients, early
may become overtly flirtatious with characterized by overt, seemingly memories are plagued by episodes
her male therapist and inform her egosyntonic demands for love and of intimidation and victimization by
therapist that it would be more sexual fulfillment.1 The patient is important adults, and boundaries
comfortable to have therapy at a unable to focus on developing may need to be reaffirmed
local restaurant. In doing so, the appropriate insights and attends frequently to prevent
patient unconsciously attempts to the sessions for the opportunity to misinterpretations of activities and
equalize the power differential by
attempting to shift the frame under
which the original therapy had been
established. The therapist may view
The appropriate response [by the therapist] to
this as flattering or just a part of
the patient’s overall pathology.
erotic transference often is to address the
Nonetheless, being aware of the recent behavior in therapy without connecting
potential pitfalls of mismanaging
the transference may be critical to it to early life experiences. This is because
helping the patient understand
current and early childhood bringing behavior to conscious awareness
relationships.
without interpretation can help to minimize the
THE CONCEPT OF
TRANSFERENCE
risk of further “flirting” or other acting out.
Transference is a crucial
component in the therapeutic
relationship and should be be close to the therapist, with the comments in therapy sessions.
incorporated into psychotherapy hope that the therapist will Sexualized transference was
education from the beginning. reciprocate love. acknowledged initially in Freud’s
During most psychiatric early writings. Freud became aware
residencies, although transference PRACTICE POINT: The of the phenomenon while working
is discussed in a general way, Therapist’s Response to closely with the case of “Anna O,”
discussion on the management of Sexualized Transference but at the time he was reluctant to
sexualized transference often is Case example. After several acknowledge such transference. It
limited. months of therapy, the patient was not until several cases later
Types of sexualized begins to make flirtatious that he realized the significance of
transference. The term comments about the therapist’s this transference. He thought it
sexualized transference is often clothing and posture in the was important that analysts
used as the most general term and room. understand “transference love,” so
encompasses at least two more The therapist emphasizes, by that they were able to
specific experiences, erotic and words and actions, the boundaries appropriately manage it.
eroticized transference. of the psychotherapeutic Unfortunately, sexualized
Differentiating between the two relationship, while controlling any transference is usually discussed in
types of sexualized transference is outward display of anxiety or the context of a therapy case
important because the intensity, the discomfort. The purpose of this where the therapist presumably
underlying motivation, and the intervention is to create an mismanaged the transference.
appropriate interventions are environment where the patient Proper management of sexualized
different. feels comfortable spontaneously transference often can be
Erotic transference. The term expressing feelings without being therapeutic, however. The nature
erotic transference is generally judged, shamed, or rejected, while of transference is that it is
reserved for positive transferences still maintaining the structure and unconscious and thus out of the
accompanied by sexual fantasies limits of the relationship. patient’s awareness. A skilled
that the patient understands to be In psychoanalytic terminology, therapist can assist the patient to
unrealistic.7 This transference does Gabbard compares the relationship identify and work through the
not interfere with the patient’s goal between the male “analyst” and issues that are involved.9
to gain insight and mature female “analsyand” to that of father The appropriate response to
attachments. and adolescent daughter.8 A father erotic transference often is to
Eroticized transference. must remain sensitive and close to address the recent behavior in
Eroticized transference is an his daughter while maintaining the therapy without connecting it to

[APRIL] Psychiatry 2007 49

Making any connection between early psychotherapy. Am J Psychother
2005;59(1):42–60.
childhood experiences and transference early 7. Koo MB. Erotized transference in
the male patient-female therapist
in the therapeutic relationship might be dyad. J Psychother Pract Res

inappropriate as there may not have been 8.

2001;10(1):28–36.
Gabbard GO. Psychodynamic
enough time to establish positive rapport. psychiatry in the “decade of the
brain.” Am J Psychiatry
1992;149:991–8.
9. Coen S. Love between therapist
early life experiences. This is may be frightened of the patient’s and patient: A review. Am J
because bringing behavior to intense emotions and tend to Psychother 1996;50(1):14–27.
conscious awareness without ignore or overreact to them.
interpretation can help to minimize Although the novice may have read
the risk of further “flirting” or other about sexualized transference, he
acting out. When such an or she may be tempted to deny its
intervention is successful, power when working with a patient
psychotherapy becomes more because of lack of confidence in
beneficial. Often the patient feels one’s ability to manage it or
less guarded and more open to because he or she believes that
gaining and utilizing insight, others will see this identification of
particularly with respect to sexualized transference as clinically
intimate feelings and concerns inaccurate or based on their own
about other important male figures narcissism.3 These issues should be
in her life. carefully addressed in supervision
Making any connection between or peer consultation if needed, so
early childhood experiences and that therapy can progress while
transference early in the appropriate boundaries are
therapeutic relationship might be carefully maintained and no serious
inappropriate as there may not boundary violations occur.
have been enough time to establish
positive rapport. Such an REFERENCES
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