Discussion

16

How Is Therapy With Women Different?

Feminist scholars have raised questions about the psychotherapy of women that have to be considered if we are to know whether the recommendations made in earlier chapters apply to the therapy of women as well as to the therapy of men, and if we are to know how therapy should be carried out depending on whether the client is a man or a woman.

Because feminist scholars—like scholars in any orientation—do not always agree with each other, the opinions of the feminists that we cite should not be taken as presenting the views of all, or even of a majority of, feminists. Further- more, we want to make clear that we are not citing the views of feminists to contradict them. Rather, we cite these views because we want to consider them seriously; and the reader will find that we agree with many of these opinions.

Sigmund Freud's views on the psychology of women changed during his lifetime. In the chapter on femininity in his New Introductory Lectures (1932/ 1964c) he softened the distinction he had previously made between the "active" man and the "passive" woman; he said, "I shall conclude that you have decided in your own minds to make 'active' coincide with 'masculine' and 'passive' with 'feminine.' But I advise you against it. It seems to me to serve no useful purpose and adds nothing to our knowledge" (p. 115). Acknowledging his incomplete understanding, Freud had conceded in an earlier work, "after all, the sexual life of adult women is a 'dark continent' for psychology" (1926/1959b, p. 212).

Keeping in mind these limitations, we proceed with our survey of feminist and of psychoanalytic views. We acknowledge that the disparagement of psy- choanalysis because it supposedly devalues women is less hotly debated in this new millennium than it was when the first edition of this book was published— not, we think, because psychoanalysis is better thought of, or because it is bet- ter understood that psychoanalysis does not devalue women, but because many people have decided that psychoanalysis is dead. As we hope has been well proven in the preceding chapters, psychoanalysis remains a vital and effective method of therapy. For this reason, it is still relevant to discuss issues sur- rounding women and psychoanalytic therapy.

Criticisms of Psychoanalytic Theory and Therapy

Some writers (e.g., Chesler, 1972; Friedman, 1979) have argued that Freud altogether misunderstood the psychological functioning of women. If Freud did

217 http://dx.doi.org/10.1037/11084-016 Resolution of Inner Conflict: An Introduction to Psychoanalytic Therapy (2nd Ed.), by F. Auld, M. Hyman, and D. Rudzinski Copyright © 2005 American Psychological Association. All rights reserved.

Co py

ri gh

t Am

er ic

an P sy

ch ol og ic al A ss oc ia ti on . No t fo r fu

rt he

r di

st ri

bu ti

on .

218 SPECIAL ISSUES IN PSYCHOANALYTIC PRACTICE

misunderstand the psychological functioning of women, the argument runs, a therapy that is based on Freud's theory of the psychological development of women is necessarily headed in the wrong direction and must do more harm than good.

Others (e.g., Gilligan, 1982; Lerner, 1988) have argued that there are spe- cial issues, particular aspects of human living that apply to women and not to men, or at least apply with greater pertinence to women. The therapist, these authors say, has to have a sensitivity to these particulars.

Some, indeed, have urged that the oppression of women in our society (in all societies? in most societies? in all patriarchal societies?) is so important to a woman's psychological functioning that this oppression must always be the fo- cus of any woman's psychotherapy. Gilbert's chapter in Women and Psycho- therapy (Brodsky & Hare-Mustin, 1980) defined feminist therapy pretty much along these lines. Rawlings and Carter (1977) advocated a feminist therapy that incorporates the political tenets of feminism. Feminist therapy, however, can either recognize the importance of the oppression of women in our society while dealing with other issues that the woman client may face in her life, or, if the therapist is quite single-minded, focus on this issue to the exclusion of any other problems in the client's life.

Finally, there is the question of whether it is better for a woman to get psychotherapy from a female therapist than from a male therapist. Marecek and Johnson (1980), participating in 1979 in a conference that assessed research on psychotherapy and women, reviewed the research that showed "the influ- ence of therapists' and clients' gender on the process of therapy; . . . the influ- ence of sex-role stereotypes on therapists' behavior toward their clients; and . . . the incidence of sexist statements and actions by therapists during the course of therapy" (p. 67). They lamented the sparseness of research on these topics, especially the lack of research that made use of observation of real thera- peutic interactions. Bernstein and Warner (1984) addressed this issue in a book called Women Treating Women: Case Material From Women Treated by Female Psychoanalysts. This book does not attempt to answer the question "Is it better for a woman to get psychotherapy from a female therapist?" through a system- atic comparison of therapy done by women and that done by men. Instead, the book presents fascinating clinical vignettes indicating some of the issues that arise in the analysis of women by women.

Did Freud Misunderstand Women?

We acknowledge that some of Freud's beliefs about the psychological develop- ment of women were erroneous. We arrive at this conclusion both from our own clinical experience of psychotherapy with women and from reading some of the extensive writings on psychoanalysis and women. We have found the discus- sion of these issues in Women and Analysis (Strouse, 1974) particularly thor- ough and illuminating.

When we grant that Freud made some mistakes in his theory of the psy- chological development of women, we do not concede that such errors make a psychoanalytic approach to the therapy of women misguided. If one takes psy-

Co py

ri gh

t Am

er ic

an P sy

ch ol og ic al A ss oc ia ti on . No t fo r fu

rt he

r di

st ri

bu ti

on .

THERAPY WITH WOMEN 219

choanalysis to be a scientific discipline—and we do—then it does not make sense to require total acceptance of all of Freud's hypotheses or total rejection of them. Whereas religious doctrines require total commitment of the believer, scientific theories do not. As Hempel pointed out, scientists accept a hypothesis tenta- tively on the basis of a sufficient body of confirming evidence (Hempel, 1965, p. 42). That new evidence may cause them to change their minds, thereupon regarding the hypothesis as disconfirmed, does not shake their confidence in the methods that brought them originally to accept the hypothesis, nor does it undermine their confidence in other hypotheses.

Accordingly, we ally ourselves with the views of Chasseguet-Smirgel. After pointing out that the articles in the book she edited (1964/1970) questioned Freud's ideas, she argued that to shrink from challenging those ideas would be to succumb to complacency and sterility. Then she said: "The vitality of any doctrine depends on the possibility of rethinking certain aspects without dis- rupting the whole structure" (p. 3).

The Moral Development of Women

In particular, we believe that Freud was wrong in saying that women have less strongly developed superegos. Granting that there are differences within each gender group in the approach of persons to morality—a fact that is well docu- mented by the research that Loe.vinger (1976) and her associates have done— there may nevertheless be something to the idea that men on the average are somewhat more rigid in their application of moral rules. It is, of course, hazard- ous to make sweeping assertions about men in general and women in general.

Alpert and Spencer (1986) provided a review of some of the research on the development of morality in men and women, together with an evaluation of what is known about it. Although they conceded that women on average may be less strict and less consistent than men in their moral judgments, they argued that differences between the sexes in making moral judgments are mostly quali- tative; that is, these differences pertain to whether the man or the woman shows concern about interest in human relations or about individual autonomy and achievement. They described Kohlberg's theory of morality as focusing on the development of autonomous rights, something that, on average, men are more inclined to be concerned about. Kohlberg acknowledged that caring, concern, and responsibility for others has not been fully assessed by his measures of moral development. Yet it is these aspects of morality, Alpert and Spencer argued, that women emphasize more than men. Accordingly, they wrote, Kohlberg's view that men surpass women in their moral development is a biased conclusion.

Gilligan (1982) and Gilligan, Ward, and Taylor (1988) likewise argued that the moral stance of women is different, that it is more attuned to human relationships and to human caring than to abstract justice. Some researchers, however, have taken issue with Gilligan's generalization about a difference, on average, between female and male ways of thinking about moral dilem- mas. In a meta-analysis of studies of morality of men and of women, Thoma (1986) found that women scored higher than men on Kohlberg's scale of moral

Co py

ri gh

t Am

er ic

an P sy

ch ol og ic al A ss oc ia ti on . No t fo r fu

rt he

r di

st ri

bu ti

on .

220 SPECIAL ISSUES IN PSYCHOANALYTIC PRACTICE

judgment. Thoma accordingly concluded that the most widely used measures of moral judgment are not biased against women, and that men are not better able to reason about hypothetical dilemmas. W. Friedman, Robinson, and Fried- man (1987); Gibbs, Arnold, and Burkhart (1984); Luria (1986); and Walker (1984) also were against the view that women are different in their approach to morality.

Schafer (1974) characterized the apparently greater rigidity of men as a "compulsive" approach. He believed that any such average differences between the sexes does not justify disparaging of women as "less moral." We agree.

We urge the reader to study Schafer's superb discussion of the morality of men and women, in which he made clear the importance of distinguishing be- tween an adaptive morality and the superego (see Blum, 1977, pp. 333-341). Schafer's final paragraph on the subject reads: "One must conclude that Freud's estimates of women's morality and objectivity are logically and empirically in- defensible. In large part these estimates implement conventional patriarchal val- ues and judgments that have been misconstrued as being disinterested, culture- free scientific observations" (Blum, p. 341).

Thus there is a point to Gilligan's argument that a male-centered point of view led Freud and some of his followers into misguided statements about femi- nine psychology (Gilligan, 1982, pp. 6-7). As we reflected on these matters and as we read what others had said, we found the way that Schafer presented a critical, current assessment of Freud's views on women's morality and objectiv- ity and women's early, prephallic development, and of Freud's sometimes con- fused, often inappropriate use of terms like "passive" and "feminine" to have much validity.

Activity and Passivity

We believe that there are, as Gilligan (1982) pointed out, important differences between the personalities of men and of women. (We will have more to say later on about these personality differences.) Gilligan argued that a focus on the im- portance of human relationships, a focus derived in women from their experi- ences of inequality and interconnection, helps to lead to constructive resolu- tions of conflict between human beings and to a valuing of justice and caring (Gilligan, 1982, pp. 62-63).

Bakan (1966) drew attention to the overall difference between women and men, in which men are often more oriented to active striving, to dealing with the external, physical environment, and to doing so in a way that emphasizes individuality, whereas women are often more oriented to dealing with relation- ships among human beings. He calls the first orientation agentic, and the sec- ond communal (pp. 102-153).

We believe that the social training of women to be more interested in inter- personal relationships and attuned to a nurturant role is not accurately de- scribed by the word passive, nor is the typical male preoccupation with the world outside the family accurately described as active. Just a little reflection should make it clear that nurturing can be very active. Nor do we believe that the training of women to be concerned about the welfare of others (sometimes

Co py

ri gh

t Am

er ic

an P sy

ch ol og ic al A ss oc ia ti on . No t fo r fu

rt he

r di

st ri

bu ti

on .

THERAPY WITH WOMEN 221

sacrificing themselves for other family members) is aptly described as masoch- istic, even though women may sometimes overdo their self-sacrifice.

Accordingly, we think it inappropriate for a therapist to urge a woman to become less assertive, when the therapist—adopting the norms of his or her culture or subculture—believes that women should be submissive. We believe that it is wrong for a therapist to take a stand on whether a woman should have a career outside the home or should devote herself entirely to the household. As should be clear from all that we have said in previous chapters, we would in- stead advocate that the therapist explore with the client the inner conflicts that play a part in making it hard for her to decide this issue for herself.

Penis Envy

Feminists consider the assertion that women and girls envy men and boys be- cause men have penises and women do not to be hardly less derogatory of women than the generalization about women's inferior morality. Feminists may mis- understand what psychoanalysts are asserting here. When the psychoanalyst says that some women believe or have a fantasy that girls and women are infe- rior, the psychoanalyst is not thereby asserting that women are inferior. It is the troubled client who made this irrational judgment, not the psychoanalyst.

Some psychoanalysts, however, seemed to think that all women—not just troubled women—believed that they had been deprived of a penis (believed so unconsciously, even if they consciously repudiated this belief). Freud built his explanation of the girl's turning away from "active, masculine" strivings, her acceptance of what S. Freud (1932/1964c, the chapter on "Femininity" in New Introductory Lectures) considered to be an appropriate "passive, feminine" posi- tion, on her confronting the shocking information that boys and men had a penis and she did not. We need to ask, first, whether penis envy is an inevitable and typical reaction of all girls, and second, whether such envy—when it does occur—is largely based on the basic facts of anatomy or, instead, owes most of its force to societal circumstances.

We have become aware, through the research done by I. Fast and her col- leagues (reported in Fast, 1984), that boys and men have dissatisfactions with their capacities and achievements, and accept the limitations of their gender with as little grace as girls and women accept the limitations of their gender. In Fast's opinion every child rails against the limitations to which he or she is subjected. The issue, said Fast, is not one of how adequate one's body is, but of what one can and cannot do. Every human being wants to accept no limits on his or her selfhood; to have to put up with such limits, as we all must do, is to suffer a narcissistic affront. For the girl, the limitations she suffers by being female rather than male can be symbolized through envy of the penis. Horney (1926) had argued that the boy also rails against his limitations, that he has an "envy of pregnancy, childbirth, and motherhood, as well as of the breasts and of the act of suckling" (p. 337).

Reik (1959) pointed out some of the consequences of a woman's unconscious conviction that she is inadequate because she is female. Horney (1926) shrewdly pointed out that male psychoanalysts see the woman's dilemma pretty much

Co py

ri gh

t Am

er ic

an P sy

ch ol og ic al A ss oc ia ti on . No t fo r fu

rt he

r di

st ri

bu ti

on .

222 SPECIAL ISSUES IN PSYCHOANALYTIC PRACTICE

from a male point of view and are, as a result, misled. Reik seems to have had some awareness of the risks of a male point of view; delightfully, he showed how the biblical story of God's creating Adam and Eve reverses the capacities of men and women. The woman in the biblical story was created out of the man's body, whereas in reality, a boy or a girl is brought out of the woman's body.

When Mead (1974) commented on Freud's 1932 article on femininity, she complained that in all cultures, "without any known exception, male activity is seen as achievement; whatever women do—gathering seeds, planting, weed- ing, basket-making, pot-making—is valued less than when the same activity, in some other culture, is performed by men" (pp. 99-100). She also enlarged on the point that Horney (1926) had made, that our society, in placing a higher value on what men do, inflicts a narcissistic wound upon girls and women. Horney argued that the "typical motives for flight into the male role—motives whose origin is the Oedipus complex—are reinforced and supported by the actual dis- advantage under which women labor in social life" (p. 337). She made the point that "we must not forget that this disadvantage is actually a piece of reality and that it is immensely greater than most women are aware of." Hence, said Horney (quoted by Mead, 1974), "In actual fact a girl is exposed from birth onward to the suggestion—inevitable, whether conveyed brutally or delicately—of her inferior- ity, an experience that constantly stimulates her masculinity complex" (p. 338).

Bardwick (1971) argued against the central importance of penis envy. First of all, she made the point, "The availability to the boy of an external, sensitive, erotic organ makes genital sex more important to him at an earlier age" (p. 11). In a somewhat contradictory vein she then said: "Those of us who have children are quite familiar with the little girl's verbalized envy of a boy's genitals, espe- cially a brother's" (p. 12). Drawing back from this concession, she continued, "But for normal girls this is an envy without intense affect, except insofar as a girl might be jealous of a boy for some real reason. If a little girl perceives a boy as receiving preferential treatment, especially from the parents, she may grasp the idea that the origin of this difference in privilege comes from the only per- ceptible physical difference between them. I believe that this allows her to make her jealousy concrete, allows her to rationalize a more general envy, and that it is less threatening to her self-esteem than questioning whether his greater privi- leges come because he may be more loved, or nicer, or smarter" (pp. 12-13). Finally, Bardwick offered this judgment: "Because of the less intense sexual impulses in the girl, I think it probable that penis envy in neurotic girls is less a function of sexual impulses than of aggressive impulses, with a concomitant desire for castration of the boy" (p. 13).

Here we find a sensitive, thoughtful, well-informed expert on the psychol- ogy of women expressing the view that at times penis envy is important in a girl's development, that at times it gives expression to deeper-lying conflicts, and that it surely is not so straightforward a dynamic as one would suppose from reading the early accounts of it by S. Freud (1905/1953b). Freud put the matter thus: "Little girls do not resort to denial of this kind [against recognizing the lack of a penis in girls and women] when they see that boys' genitals are formed differently from their own. They are ready to recognize them immedi- ately and are overcome by envy for the penis—an envy culminating in the wish, which is so important in its consequences, to be boys themselves" (p. 195).

Co py

ri gh

t Am

er ic

an P sy

ch ol og ic al A ss oc ia ti on . No t fo r fu

rt he

r di

st ri

bu ti

on .

THERAPY WITH WOMEN 223

Despite Freud's prestige, which predisposes us to accept his views unless there is strong contrary evidence, a number of contemporary psychoanalysts have come to the conclusion that usually observation of the differences between male and female sexual anatomy is not the decisive factor in a woman's devel- oping penis envy. According to these authors (who include Torok, 1964/1970), awareness of objective anatomical differences does not account for the idealiza- tion of male genitals, and the absence of a body part—namely, the penis—does not in itself produce pathological envy or self-depreciation. Torok holds this view even though she recognizes that many female clients attribute their sense of deficiency to their lack of male genitals.

The underlying conflicts that find expression in an envy of the penis and of the male role include narcissistic injuries, deprivations of love, and provoca- tions to envy. Grossman and Stewart (1977) pointed out that such underlying conflicts could find metaphoric expression in penis envy. According to these au- thors, the discovery of differences between the male and the female genitals is only one among many possible experiences of deprivation, all of which would lead to feelings of deprivation and to self-disparagement.

Lerner (1980) reported that in her experience as a clinician, the woman who devalues femininity and desires a penis usually does so because of a dis- turbed relationship with her mother:

The female child may desire a penis in order to better express her hatred toward her mother, or as a means of possessing the envied omnipotent mother and her magical attributes, or as a means of extricating herself from a de- pendent and frustrating relationship with mother—that is, as a desperate attempt at separation and differentiation. Penis envy may be an expression of a revolt against the narcissistic wounds inflicted by the omnipotent mother or may be the girl's attempt to protect a jealous, intrusive, maternal imago by making an unconscious "oath of fidelity" to the mother that she (the daugh- ter) will not achieve genital fulfillment (Chasseguet-Smirgel, 1970; Torok, 1970; Lerner, 1977). (pp. 49-50)

Lerner also pointed out that when a girl experiences her mother as dominant and controlling—as destructive, castrating, and bad—the girl may try to avoid being like her by imagining herself to be weak, powerless, and "castrated."

In the article by Torok (1964/1970) that Lerner cites so frequently, Torok shows in a most impressive way how the little girl who had a domineering, intrusive mother, a mother who tried to meet her own needs through keeping her daughter for herself, would produce a child who felt compelled to give up her genital strivings and her basic womanliness. Such a girl would imagine that a man's penis gives power and would idealize that penis; what she could not do is accept a mutual giving with a man, one that would allow both of them pleasure and mature functioning. Such a girl would renounce sexual maturity and pleasure. Her fantasy that a man's penis gives him everything serves a defensive function. It spares her from the temptation to turn away from her mother; the girl fears that the price of separating herself from her mother will be her mother's abandonment and her own annihilation.

It can be seen that in Torok's view, penis envy develops out of a distorted object relationship with the girl's mother. It turns on the issues of control ver-

Co py

ri gh

t Am

er ic

an P sy

ch ol og ic al A ss oc ia ti on . No t fo r fu

rt he

r di

st ri

bu ti

on .

224 SPECIAL ISSUES IN PSYCHOANALYTIC PRACTICE

sus autonomy, separation, and the girl's movement toward a mature sexuality. And, Torok writes, the boy is faced with similar conflicts when he has a control- ling mother whom he is afraid to declare his independence from, and a father whom he is afraid of challenging by asserting his own genital desires. Within this framework, the boy will defensively construct the fantasy that a woman is an inferior creature, ready to be subjugated. In this way the boy, out of his own fear of a mature sexuality, adopts what Torok (1964/1970) called "this phallo- centric prejudice, old as humanity itself (p. 170).

The Female "Oedipus Complex"

Freud's theorizing about the female "Oedipus complex" was consistent with his views about other aspects of female psychological development (see S. Freud, 1932/1964c, pp. 132-135). One central element in those views was the conceptualization that men relate emotionally and unconsciously to their par- ents as depicted in the myth of Oedipus; that is, men love their mothers and compete with and wish to destroy their fathers. Women relate to their parents in the opposite way, hating and competing with their mothers and loving their fathers. Freud assumed that in resolving the Oedipus complex, boys renounce their mothers (under the threat of castration by the father), identify with their fathers, and internalize the strong morality personified by the fathers. He be- lieved that girls, on the other hand, were unable to achieve the same resolution of the Oedipus conflict because, seeing themselves as castrated, they had no motive to renounce the father as the love object. He believed that women, lack- ing this motive to identify with the father and to internalize the morality that the father personified, would as a result turn out to be weak, powerless, and without the same moral fiber as men. In our opinion, even though it is possible that a woman might come to experience her parents emotionally according to such a pattern, and reveal it during her psychoanalytic therapy, it makes no sense to expect such a pattern in all women.

This early conceptualization of the female Oedipus complex carried with it notions about the expectations analysts should have about the analysis of women and its outcomes. For example, the stereotypical image of the woman as a mem- ber of the "weaker" sex, subordinate to men and emotionally fit primarily for domesticity and childbearing, led some analysts in the past to view assertive- ness in a woman as a defense against castration, a protestation of "maleness"— something to be analyzed and resolved. Indeed, it seems that it was the stereo- type of the times that dictated the psychodynamic formulation of the female Oedipus complex rather than observations made during psychoanalytic work.

Psychoanalytic thinking and practice in regard to female development have gone far beyond the earlier conceptualization. Although this brief discussion of psychoanalytic techniques and practices cannot include a comprehensive re- view of the vast literature on alternatives to the classic view of the issues, we can note that, in general, emphasis has shifted from the oedipal stage to the so- called preoedipal one. The preoedipal period is characterized by, among other things, the essential emotional attachment of mother and daughter as a critical element in the psychological development of women. A noteworthy example of

Co py

ri gh

t Am

er ic

an P sy

ch ol og ic al A ss oc ia ti on . No t fo r fu

rt he

r di

st ri

bu ti

on .

THERAPY WITH WOMEN 225

the importance of this earlier period is supplied by Kulish and Holtzman (1998), who proposed that, in so far as women are concerned, the Oedipus myth might well be replaced by the Persephone myth, which would provide the prototype of the attachment of women to their parents. The myth tells of the intensity of the attachment of mother to daughter, the anguish that ensues when the daughter separates from the mother to enter into womanhood and motherhood, and the competition between mother and father for daughter's affection. At the very least, Holtzman and Kulish's suggestion takes account of the complexity of at- tachments during female psychological development, a complexity that is not inherent in applications of the Oedipus complex.

Further, psychoanalysis in general has been focusing increasingly on preoedipal issues in the treatment of both men and women. This trend has been supported by the study of the psychology of attachment during development, a trend that has certainly been encouraged by psychoanalytic theorizing about the psychology of women.

The shift in focus in psychoanalysis from the oedipal stage to preoedipal development in both men and women has been paralleled by a shift away from the study of clients' inner, unconscious psychic life to an examination of rela- tionships and attachments both in and out of awareness. Technique has also changed. The current model seems to be of a psychoanalysis that includes more interaction, discussion, and examination of the consciously presented aspects of the client's emotional life. One encounters less and less the idea of psychoanaly- sis as formulation of psychic conflict through examination of associations, a formulation ultimately to be presented in the form of an interpretation. Fur- ther, that which is presented by the analysand is frequently considered veridical rather than an association that is a covert communication from the unconscious needing to be deciphered.

As we have emphasized throughout our various presentations in this book, we value the individuals with whom we work as autonomous, self-sufficient persons who, despite their inner conflicts, are fully able to be responsible for their lives. Therefore, we advocate that the therapist first analyze conflicts that ensue from an experienced relationship, in the manner we have been describ- ing, before turning to other techniques.

Clitoral and Vaginal Orgasms

Finally, we take up the points that Sherfey (1972) emphasized. In the first chap- ter of her book, Sherfey disputes S. Freud's (1905/1953b, pp. 220-221) argu- ment that the girl in her sexual development first experiences excitement and pleasure through the clitoris but later experiences excitement and pleasure vaginally. As Sherfey put it, "One of Freud's most useful, accepted, and endur- ing concepts is his theory of female psychosexual growth with its basic assump- tion that the female is endowed with two independent erotogenic centers; dur- ing development she must transfer the infantile erotogenic zone of the clitoris to the mature erotogenic zone of the vagina" (p. 21). Sherfey argued that the research of Masters and Johnson (1966) demonstrated a similar physiological response during clitoral masturbation and during coitus. Accordingly, Sherfey

Co py

ri gh

t Am

er ic

an P sy

ch ol og ic al A ss oc ia ti on . No t fo r fu

rt he

r di

st ri

bu ti

on .

226 SPECIAL ISSUES IN PSYCHOANALYTIC PRACTICE

wrote, there is just one kind of orgasm and that orgasm always derives from stimulation of the clitoris. It would make no sense then to suppose that women who did not have a "vaginal orgasm" (which could not exist, Sherfey argued, because all orgasms were the same) were flawed or backward in their psycho- sexual development.

Moore (1977) in his chapter in Blum's book, concedes that "Sherfey estab- lishes fairly convincingly her thesis that vaginal orgasm as distinct from clito- ral orgasm does not exist physiologically" (p. 309). But, Moore argues, "her state- ment that These findings force us to the conclusion that there is no such thing as psychopathological clitoral fixation; there are only varying degrees of vaginal insensitivity and coital frigidity' (p. 101) is not consistent with her own admis- sion that 'clitoral fixation very obviously can, and very often does, interfere with vaginal functioning' (p. 42)" (p. 310).

So, Moore continues,

The crux of the matter seems to be the issue of physical versus psychic sat- isfaction. As in the case of her objections to the role of bisexuality in female sexuality ... so also in regard to clitoral and vaginal erotogeneity, Sherfey overlooks the truth that the anatomical and physiological facts, though im- portant, are of less consequence clinically than their psychic representation. Hysterical anesthesias do not conform to the anatomical distribution of nerves but to the clients' erroneous concepts of the body. Distortions of previously learned anatomical facts about the genitals are frequently observed in ana- lytic practice, and the facts Sherfey marshals have been, she says, previ- ously unknown, or in some instances curiously ignored or neglected even by biologists. Could more be expected of patients? (p. 310)

Piskorz de Zimerman (1983) argued that some psychoanalysts, believing that a woman should enjoy a vaginal orgasm, psychologically damage their fe- male clients. In the next section of the chapter we comment on this issue.

How Should We Deal With the Inadequacies of Freud's Theory?

In the light of what we said about accepting scientific hypotheses when there is evidence for them and abandoning them when there is evidence against them, we have no choice but to give up Freud's view that women are deficient in their superego development. We must be careful, also, to distinguish between those receptive and nurturant attitudes that in most cultures are more prominent in women than in men, and the masochistic attitudes that Freud (in some of his statements) attributed to women generally. Although some women and some men are masochistic—they may express this through self-defeating actions— we see no reason to think of masochism as a naturally feminine trait. It may be that in our society girls are taught, more than boys, to sacrifice themselves for others, and to do so even when it doesn't make any sense. If, as a result of such training, women are more self-sacrificing, we believe it does not contribute to our understanding of this result to call it masochism.

Co py

ri gh

t Am

er ic

an P sy

ch ol og ic al A ss oc ia ti on . No t fo r fu

rt he

r di

st ri

bu ti

on .

THERAPY WITH WOMEN 227

Friedman (1977), in defending psychoanalysts against the charge that they try to make women submissive and discourage autonomy, offered several de- tailed case examples of interpretive treatment of women's excessive passivity. We recommend that the reader emulate his example: Every human being, both male and female, should be helped to overcome excessive passivity.

Freud's formulation of the penis envy hypothesis presents a more complex problem than his formulation of the "weaker superego" and "masochism" hy- potheses, because he captured in this hypothesis a bundle of fantasies that play an important role in the girl's psychological development. From the partial knowl- edge that we now have (partial because relatively little research has been done on how boys and girls think about their bodies and on what impact this has on their psychological development), we judge that for many women, penis envy is not strong enough to play a decisive role in their adaptation. We believe that where penis envy is intense it bespeaks a pathological development, as Grossman and Stewart (1977), in Blum's book, argued. Penis envy, these authors believed, symbolizes the woman's dissatisfaction with herself; exactly what she is dissat- isfied with and why remain to be discovered and cannot be taken for granted.

As for the impact of the mistaken belief that women develop a capacity for a vaginal orgasm (i.e., for the arousal leading to orgasm that depends on stimu- lation of the vagina) and outgrow a clitoral orgasm, we believe that what mat- ters in the woman's psychological development has to do with her fantasies about sexuality and with her mental representations of her sexual anatomy, her sexual activity, and her sexual relationships. In our view, what matters about the woman's psychosexual development has little to do with the facts of sexual physiology and sexual anatomy.

We believe that it would be a mistake to browbeat a woman client because she feels pleasurable sensations that she attributes to her clitoris, and yet does not have any pleasurable sensations that she attributes to her vagina. The thera- pist who takes fantasies and mental representations as seriously as we think he or she should would focus on these issues: Does this woman believe that she can use her vagina as a part of providing pleasure to herself? When she has feelings of love for a man, does it give her satisfaction to have coitus? In having sexual intercourse, does she think of her vagina as a valuable part of herself?

If she disparages her genitals (unconsciously derogating herself as inferior because she is female), we believe that this self-disparagement deserves analy- sis. The reader can appreciate, however, that overcoming this self-disparage- ment has nothing to do with a focus on the sexual anatomy as an objective fact; it is the person's fantasies about the anatomy that have to be dealt with.

What Special Problems Do Women Have?

We believe that psychotherapists need to be aware of (a) the different character structures of women and men, (b) the different role demands placed on women and men, and (c) the different problems that are typical of women as compared to men. Gilligan (1982) pointed out that women are typically more concerned with relationships among human beings and are more disposed to be nurturant of others. Murdock (1949, pp. 7—8) argued that the division of labor by sex had

Co py

ri gh

t Am

er ic

an P sy

ch ol og ic al A ss oc ia ti on . No t fo r fu

rt he

r di

st ri

bu ti

on .

228 SPECIAL ISSUES IN PSYCHOANALYTIC PRACTICE

adaptive advantages for the societies that adopted such divisions. Such role prescriptions would be expected to lead to normative personality patterns for the two sexes. Erikson (1968) made a similar point when he spoke of "what [women] have always stood for privately in evolution and in history (realism of householding, responsibility of upbringing, resourcefulness in peacekeeping, and devotion to healing)" (p. 262).

Terman and Miles (1936) had already shown that men and women differ markedly in their interests: Men on the average are more interested in compe- tition, aggression, business pursuits, and science and engineering; women are generally more interested in human interactions. The comprehensive research by Maccoby and Jacklin (1974) provides a later view of these differences, and the works by Basow (1986, especially pp. 61-73), by Maccoby (1998), by Wood and Eagly (2002), and by Bornstein and Masling (2002) still later views. Even today, the sexes differ along these lines in their preferences for television pro- grams and for reading materials (in books and magazines), as marketing and advertising researchers are well aware.

A current fashion in social psychology involves denial of consistent gender differences; the social psychologist is inclined to attribute any gender distinc- tions to the impact of societal pressures. Yet the social constructivist approach can be shown to be inadequate to explain gender differences, according to Archer's (2004) recent review of the literature.

What implications do such sex differences in personality have for psycho- therapy? These differences mean, at the very least, that a male therapist has to make a special effort to experience a female client's living, just as the female therapist has to do to experience a male client's living.

Besides the bare fact of a difference between the personality structure of men and women, there is the issue of the injustices visited on women by our society, out of its "phallo-centric prejudice," as Torok put it. Although women therapists, and male therapists who come from marginalized groups within our society, may intuitively respond to these injustices, the white, male therapist may well be inclined to discount the impact of these injustices. If he fails to give due weight to them, the female client will have good reason to believe that he does not understand her and her life.

Accordingly, we recommend to therapists that they apply to their work with women the advice that Grier and Cobbs (1968) gave to therapists about work with Black clients, adapting that advice as needed to the circumstances of the wrongs done to women. In their chapter "Mental Illness and Treatment," Grier and Cobbs provided a superb discussion of how the therapist needs to combine an understanding of the cultural conditions that shape a person's life and provided a framework within which that person must adapt with insight into the inner conflicts that the person is struggling with. They wrote

Fundamentally one wonders why there should be anything singular about a Negro's mental troubles. We would like to answer that right away. There is nothing reported in the literature or in the experience of any clinician known to the authors that suggests that black people function differently psycho- logically from anyone else. Black men's mental functioning is governed by the same rules as that of any other group of men. Psychological principles

Co py

ri gh

t Am

er ic

an P sy

ch ol og ic al A ss oc ia ti on . No t fo r fu

rt he

r di

st ri

bu ti

on .

THERAPY WITH WOMEN 229

understood first in the study of white men are true no matter what the man's color. . . .

In sum, let us enter a plea for clinical clinicians who can distinguish unconscious depression from conscious despair, paranoia from adaptive wariness', and can tell the difference between a sick man and a sick nation, (pp. 154, 157-158)

They recommended that the therapist first take account of the realistic conditions of the client's life, acknowledge these to the client, and, having taken account of this reality, then forcefully show what remains to be explained as a personal characteristic, a result of the client's conflicted inner life. They gave an affecting example of therapeutic work with a troubled Black woman who had paranoid symptoms, Miss Y. This woman was first seen during an acute psychotic episode. Describing the therapeutic work, Grier and Cobbs wrote

She felt on one occasion that she (the only black person at her rather high level) was being discriminated against and being denied a promotion simply because she was black. When asked for specific evidence of this, she said that other workers less skillful than she and with shorter tenure on the job were being promoted while she remained at the same job. . .. The therapist agreed with her on the general prevalence of racial prejudice in work situa- tions and added that it seemed more of a problem at higher job levels. She was asked about other evidence of racial discrimination and what remedies if any were available to employees. ... As other examples of prejudice she recalled a co-worker who had been very friendly but who lately was cool and disinclined even to speak to her. . . .Such examples prompted the therapist to raise the question of her illness. She had, after all, behaved rather strangely at work on more than one occasion and her co-workers knew that she had been hospitalized for her emotional ailments. Could it be that they were afraid of her because of her symptoms?

She thought for a long while and then burst into laughter. "Those bas- tards are not too well put together themselves! I'd probably scare the hell out of them if I said 'Boo!' And they must be really tied up in knots over what to do with this crazy nigger woman who's got such a big job!"

She laughed herself breathless, and as she wiped away the tears the therapist felt tears start in his own eyes, but from a more solemn source than the tears of the laughing woman who needed to be laughed with but who needed also to be wept for. (pp. 159-160)1

Grier and Cobbs went on to comment, "This unhappy woman had to deal not only with the prejudices of her co-workers toward the mentally ill and to- ward women but with the additional factor of her being Black as well. She had to separate her own pathological suspicions from the reactions of fellow work- ers, which were troublesome enough but, as she observed, also compounded by her being a 'crazy nigger'" (pp. 159-160).

We believe that the strategy advised by Grier and Cobbs can and should be adapted to the situation of women, who suffer injustices because they are women.

'From Black Rage, by William H. Grier and Price M. Cobbs. Copyright 1968 by William H. Grier and Price M, Cobbs. Reprinted by permission of Basic Books, Inc., New York.

Co py

ri gh

t Am

er ic

an P sy

ch ol og ic al A ss oc ia ti on . No t fo r fu

rt he

r di

st ri

bu ti

on .

230 SPECIAL ISSUES IN PSYCHOANALYTIC PRACTICE

Dr. Sandra Pyke of York University in Toronto expressed a similar viewpoint in a lecture she gave at the University of Windsor (Pyke, 1984). She made the point that the woman who has suffered injustice cannot confront her own inner conflicts until she, and the therapist, have acknowledged the real injustices.

Should Every Therapy Focus on Oppression? The reader who has carefully followed our argument to this point knows that we would not advocate that every therapy of a woman should focus on the op- pression of women in our society. Nevertheless, we will spell out how we ar- rived at that conclusion.

First of all, psychotherapy according to psychoanalytic principles deals with what is important for the client, for this client at this time. The therapist at- tends to what the client brings forward; he or she attempts to stay with the current flow of material and with what is preconscious or about to become pre- conscious. The therapist cannot be doctrinaire about what kind of material that might be. If he or she is doctrinaire, insisting on dealing with some particular material that the therapist believes to be important, the therapeutic situation is turned into one in which the therapist exercises authority over an obedient client. Clients, male and female alike, are already too familiar with other hu- man beings who deal with them in an authoritarian way; there is no advantage in the therapist's doing so, even in the name of "freeing her from oppression."

Second, the psychoanalytic therapist wants to deal with the client's living as he or she experiences it, focusing on the inner life, on conflict, and to avoid doing anything to strengthen the client's tendency to divert her (and the therapist's) attention from inner life to external experience (see, for example, Bollard, Auld, & White, 1953). The therapist and the client will misunderstand the psychodynamic processes if they attribute the problem solely to externals, just as Freud misunderstood the development of neurosis in his clients when he held to the seduction theory (see Gay, 1988, pp. 90-96).

Nevertheless, we insist on the importance of culture in defining the world in which the person lives and creating the ground in which neurosis grows. Kovel (1976) stated the matter eloquently:

Neurosis springs not from some mysterious estrangement from nature, nor from "immortal ambivalence," nor from suppression of mystification in the family, nor from somatic constitution, but rather from the total societal or- ganization—in this case, advanced capitalism—as it imposes contradictions upon all the forms of personal life.

So long as we have a dominative society with division of labor, alien- ation and class distinction, its splits will devolve into family life and, given the natural susceptibility of human infants, will produce neurotic charac- ters of one kind or another, (p. 151)

Even though the ultimate causes of neurosis are social, Kovel argued that the therapist has to deal with proximal causes. He wrote,

What the radical therapists forgot in their analysis was the distinction be- tween the ultimate cause of a phenomenon such as neurosis and its actual

Co py

ri gh

t Am

er ic

an P sy

ch ol og ic al A ss oc ia ti on . No t fo r fu

rt he

r di

st ri

bu ti

on .

THERAPY WITH WOMEN 231

manifestation. The harsh truth is that once neurotic repression sets in, whether at the behest of a repressive parent or by the alienated child's own effort to stem his feeling of inner chaos, the ensuing neurotic structure takes on a life of its own, becomes invisible.... Thus radical therapists—whether they be feminists, gay liberationists or straight Marxists—who fancy that a direct appeal to visible oppression will unsnarl the inner invisible twisting are simply tilting at windmills, (pp. 252-253)

Accordingly, we urge the therapist to take account of the client's realistic life situation, to acknowledge it, but to involve herself or himself in a therapy that exposes the client's inner life. Such a therapy, as Kovel pointed out, can bring about a helpful change in the client's life, even if it cannot bring heaven on earth.

Should Women Treat Women?

There is, to the best of our knowledge, no definitive research to tell us whether women do better, on average, as therapists of women than men do. In Shafter's (1988) opinion, research studies have provided no evidence that male or female therapists are more likely to produce a successful therapeutic outcome. We do not mean to suggest that little has been written on this subject; the interested reader is invited to consult articles by Cavenar and Werman (1983); Felton (1986); Fenton, Robinowitz, and Leaf (1987); Goz (1973); Jones, Krupnick, and Kerig (1987); Jones and Zoppel (1982); Kaplan (1985); Kirshner, Genack, and Hauser (1978); Kulish (1984,1986); Orlinsky and Howard (1976); Schover (1981); Shainess (1983); and Tanney and Birk (1976). Because most of these articles rely on case material rather than on systematic study of the gender variable, we believe Shafter's opinion to be correct.

Schachtel (1986) pointed out important ways in which sex roles influence the interaction between client and therapist; but she did not offer any sweeping recommendation about whether a male or a female therapist is to be preferred. Kaplan (1979) discussed some issues affecting the therapeutic relationship that stem from the gender roles of the therapist and the client. Lerner (1988), after listing seven purported advantages of having a female therapist for a female client, qualified her recommendation in this way: "As is true of all generaliza- tions, those stated here tell us nothing about the advantages or disadvantages of a particular therapist or the unique needs of an individual patient. Surely, being male does not condemn one to tunnel vision or to a rigid and unexamined adherence to patriarchal attitudes" (p. 139).

From the work of Kulish (1989) we now know that some experienced fe- male psychoanalysts are persuaded that the analyst's gender does have an im- pact on the transference, especially on the sequence in which material emerges in the therapy. She pointed out, "it is striking how frequently the idea of coun- tertransference turned up" in the conversations that she had with the 17 senior female analysts whom she interviewed (p. 70). Kulish continued,

What seemed to filter through the wide variety of responses was the idea of a gender-related perceptual biasing, a sort of "cognitive set." Gender may serve as a basic, unconscious organizing factor around which clinical mate-

Co py

ri gh

t Am

er ic

an P sy

ch ol og ic al A ss oc ia ti on . No t fo r fu

rt he

r di

st ri

bu ti

on .

232 SPECIAL ISSUES IN PSYCHOANALYTIC PRACTICE

rial is experienced, processed, understood, and interpreted. This processing would, in turn, interact with and influence the patient's experience of the transference, so that the various factors contributing to the final amalgam would be very difficult to decipher, (p. 70)

We recommend Kulish's article as a thoughtful survey of these issues. (See also Kulish & Mayman, 1989; Kalb, 2002.)

Raphling and Chused (1988) believed that at times the gender of the ana- lyst could be used as an organizer of and resistance to certain transference manifestations. They discussed the factors that contribute to the availability for analysis of cross-gender transference, and the obstacles to this analysis.

On the topic of countertransference, we want to cite Ruderman's (1986) discussion of how women therapists use their emotional reactions to their fe- male clients, often in creative and restorative ways, in their therapy of these clients. Although Ruderman writes of countertransference, she intends much more than the unconsciously determined reactions to the client; she wants to consider the therapist's realistic reactions to the client as well. In her research on the feelings of analytic therapists toward their clients, Ruderman identified five themes: the therapist's relationship with her or his mother, fear of success, role conflicts, envy in the countertransference, and the therapist's life stage.

The first three of these themes we take to be examples of the shared life experience of a female therapist with a female client, a sharing that is likely to facilitate the therapist's empathy with and understanding of the client. Of the fourth theme Ruderman wrote, "Envy in the countertransference was associ- ated with the reactivation in the therapist of dependency wishes, conflicts about autonomy, and mourning for lost or absent opportunities for gratification in her past life. Envy has its productive and constructive elements; if resolved, it leads to admiration and awe. It can also lead naturally to a process of mourning . . . for what was, what was not, and what can never be" (p. 355).

In discussing the fifth theme, Ruderman remarked that the therapist's life stage—most of the therapists she studied were in midlife—had a strong effect. One therapist, for instance, "described her intense inner responses to her patient's youthful and flowering life," realizing that "the abundant options now available to her woman patient" had not been available to her when she had been young (p. 357). Another therapist, who in her own life now felt a particular need for the support of her family and friends, stressed to one of her clients "the importance of relationships and family ties" (p. 358). Ruderman concluded: "Fi- nally, the female therapists in this study, and perhaps women in general, reso- nate in a particular way with each other. They have much to share, and many steps to climb together" (p. 360).

We need to be alert to the possibility that a male therapist can lack an appreciation of the circumstances of a woman's life, can moreover be a prisoner of the phallocentric assumptions of our society. Sesan (1988), making use of questionnaire data, reported that the majority of the 192 former clients of 49 psychotherapists believed that they had been treated in a sex-fair manner. Ac- cording to Sesan, women with the least formal education and women who had children experienced more sexual bias than other women. She found bias "in

Co py

ri gh

t Am

er ic

an P sy

ch ol og ic al A ss oc ia ti on . No t fo r fu

rt he

r di

st ri

bu ti

on .

THERAPY WITH WOMEN 233

the areas of fostering traditional roles, lack of acceptance of anger, and lack of a sociocultural context in the therapy" (p. 107).

Some psychoanalytic writers believe that the gender of the therapist does not matter. These writers argue that transferences to both mother and father are elicited by either a male or a female therapist. They concede that the order in which transferences will be experienced and expressed may differ, depend- ing on the sex of the therapist; nevertheless they insist that in due time all the transferences will appear. Blum (1977) and Zetzel (1970) wrote that, in their experience, oedipal transferences always adapt to the gender of the analyst. Karme (1979) said that the preoedipal transferences occur whether the thera- pist is female or male. She believed that female therapists rarely experience father transferences, whereas male analysts regularly experience preoedipal mother transferences. Galenson (1986) argued that transference elements of all types can be fully explored no matter what the sex of the therapist.

We ourselves are not so sure about this. We would like to see systemati- cally gathered, empirical evidence. Until we have that kind of evidence, we will refrain from reaching any firm conclusion about whether it matters if the thera- pist is male or female, and how it matters. We only know that women have often done very well as the clients of male therapists, probing deeply into con- flicts that touch on their gender identity; and that men have often done very well as clients of female therapists, doing the same type of probing.

Moldawsky (1986), in our opinion, made an important contribution to our understanding of how the gender of the therapist matters. First he quoted Mogul (1982), who after surveying more than 80 articles about the gender of the therapist concluded that the sex of the therapist matters most in face-to- face therapies that are less intensive. Presumably such therapies would em- phasize the real relationship of client and therapist more, and the transfer- ence less.

Moldawsky then quoted Person (1983), who suggested four conscious rea- sons for women's choice of female analysts: (a) fear of sexism from a male ana- lyst; (b) avoidance of "faking it," that is, of feeling subject to the need to please a man; (c) fear of erotic transference and countertransference; and (d) a wish for a role model. In discussing these points, Moldawsky made clear that the first three issues can be handled appropriately when the female client has a male analyst if the male analyst refrains from sexist attitudes and the female client gradually overcomes her wish to ingratiate herself to a man and her conflicting feelings in an erotic transference.

Moldawsky (1986) then proceeded to give telling examples of the preoedipal transferences that he had observed in women clients. He pointed out that the therapist's nonintrusive, nonjudgmental, and interested stance provides a strong provocation to the development of a preoedipal transference. He said, "Nowhere is there a more consistent nurturant atmosphere than in analysis. Hour after hour, the analyst sets aside his or her own interests and needs and devotes attention to the patient" (p. 294).

In conclusion, Moldawsky asked, "Can the female patient have the same living through experience in a preoedipal transference with a male analyst as when she is seeing a female analyst?" He answered,

Co py

ri gh

t Am

er ic

an P sy

ch ol og ic al A ss oc ia ti on . No t fo r fu

rt he

r di

st ri

bu ti

on .

234 SPECIAL ISSUES IN PSYCHOANALYTIC PRACTICE

I am convinced that the male analyst can help a female patient live through a preoedipal mother transference. I do not know, however, whether it is experienced in the same way when both members of the dyad are female. Gender should make a difference ... certain feelings will be facilitated with an analyst of one gender but. . . over the long term, all the conflicts will be experienced in the analytic relationship with an analyst of either sex. How- ever, all the feelings may not necessarily be "lived through." The question for research, then, is whether or not this makes any difference, (p. 302)

Conclusion

Having reviewed some of the literature on psychoanalysis and women, and hav- ing reflected on our own experiences in doing therapy with women, we came to several judgments that may be summarized as follows:

1. Freud was mistaken in believing that the consciences of women are less well developed than the consciences of men. Although this judgment disparages women, the damage that this erroneous be- lief does to the therapy may sometimes be less than one would suppose.

We draw this conclusion because we believe that no therapist is completely free of biases; no one is perfect. Yet that does not pre- vent therapists from doing effective work much of the time. To draw an example from Freud's therapeutic work: Even though his belief that the superego of a woman is less well developed than that of a man surely disparages women, he often admired women and valued them highly. He must have had admiration for his cli- ent H. Doolittle (his letters to her that she reprints in her book Tribute to Freud seem to show this), for she would not have put up with condescension. Ms. Doolittle did in fact develop a strong work- ing alliance in her therapy with Freud, as well as a personal friend- ship. (See her book [listed as written by "H. D.," 1956] and Fried- man, 1987.) Thus we believe that it is a matter to be decided empirically: Does the therapist's misguided belief system hinder work with the client?

2. Freud was wrong in believing that women are more passive and more masochistic. We think that believing that passivity is natu- ral for women may be mischievous, leading a therapist to suppose that women should refrain from appropriate self-assertion. We think that believing that women are naturally masochistic may lead a therapist to suppose that a woman has sought suffering and likes it, in the absence of any solid evidence that this is in fact so. We believe that some women, at some times, bring suffering on themselves, just as some men, at some times, do. In our opinion one should insist on evidence for such a judgment in the case at hand before accepting it.

3. There is such a thing as penis envy, and some women suffer from it. Where the intensity of penis envy leads a woman to be exces-

Co py

ri gh

t Am

er ic

an P sy

ch ol og ic al A ss oc ia ti on . No t fo r fu

rt he

r di

st ri

bu ti

on .

THERAPY WITH WOMEN 235

sively competitive with men, and where that overcompetitiveness and hostility prevent her from achieving the loving relationship with a man that she wants, penis envy is indeed a problem that psychotherapy should address.

On the other hand, it has not been our experience that the ma- jority of women—even of women who are clients in psychotherapy— are so competitive with and hostile toward men that it interferes substantially with their relationships with men. Because we be- lieve in looking for evidence for any characteristic before attribut- ing that characteristic to a client, we think it damaging to good therapy to assume automatically that every woman suffers from penis envy.

4. There are many problems of living that have a special twist in the life of a woman. It should be a great advantage for any therapist, male or female, to develop a deep appreciation of the special prob- lems that women face. Furthermore, the therapist would be well advised always to concede the realistic problems in the client's life and then ask, "What more is there to your problem, after we've taken this into account?"

5. We do not know fully the impact of having a therapist of one gen- der or the other. We believe that no one is now able to give a confi- dent answer about what difference the gender of the therapist makes. There is preliminary evidence that the therapist's gender has an impact on the readiness of the client to express oedipal transference feelings; accordingly, this expression may come some- what earlier or later depending on the therapist's gender. There is also preliminary evidence that preoedipal transferences will de- velop regardless of the therapist's gender. We acknowledge that the female therapist can serve as a model for her female client; this may be an advantage.

We believe that when a male therapist falls into prejudices against women, allowing these to hinder his handling of the therapy, his mistaken behavior should be labeled countertransference. It is equally an instance of countertrans- ference when a female therapist consciously or unconsciously allies herself with her female client's complaints about bigotry on the basis of gender and, re- sponding to these complaints, sympathizes with her rather than analyzing these verbalizations or considering them a part of the client's free associations. (What we said in chap. 7 about countertransference gives our recommendations about how to avoid such mistakes.)

The therapist, however, need not fall into such mistakes. When a female therapist encounters a female client who holds forth at length about the injus- tices she endures as a woman, seeking to enlist the therapist as an ally in the client's war against men—and when the therapist would not be wrong to con- sider this ploy of her client to be a defensive maneuver, concealing from both the client and the therapist an underlying conflict—then the therapist must resist the all-too-human tendency to join in with her client in the struggle against men. The therapist's own unresolved feelings about the injustices that

Co py

ri gh

t Am

er ic

an P sy

ch ol og ic al A ss oc ia ti on . No t fo r fu

rt he

r di

st ri

bu ti

on .

236 SPECIAL ISSUES IN PSYCHOANALYTIC PRACTICE

society has imposed on women may make it difficult for her to resist the client's provocation.

In similar fashion, when a male therapist faces a provocative female client who tries unconsciously to provoke a combative, antifeminist response, the thera- pist is well advised to keep his composure. We recall how a colleague, whose first name (Carroll) left some doubt to anyone who had only heard his name whether he was male or female, handled such provocation. When his client, a 33-year-old woman, encountered him for the first therapy session, she exclaimed, "Oh, you're a man! I'd wanted a woman therapist. Male therapists can't really understand a woman's life."

The therapist inquired what experiences had led the client to assume that a male therapist would lack understanding. He accepted this woman's current experience of mistrust as a real and troubling experience (not to be discounted or argued away) and took it as material for analytic understanding. His client did agree (without coercion) to try to work with the therapist, and as it turned out, they developed a good working relationship. This client's therapy was help- ful to her, despite her initial belief that a man could not possibly understand her.

As we said in the chapter on personal responses of the therapist (chap. 7), we do not view all of the responses of the therapist to the client as countertrans- ference. Thus in our view it is not inevitable that the gender of the therapist will adversely affect the therapeutic process, any more or any less than it would be inevitable that other attributes of the therapist would do so. All responsible therapists will be alert for indications that their gender is having an impact on the therapeutic process and will take steps to analyze their reactions that give such evidence, as a means to understanding themselves, and their clients, more fully. Just because it is possible that gender may become a significant issue in the therapy, one is not justified in assuming that gender will always be an issue (and that special measures have to be taken to deal with it).

Thus the answer to the question, "Is the therapy of women different?" is yes and no. Surely the woman client has some problems that are unique to women. She may at times feel more comfortable with a female therapist (but whether this will enable her to deal with her problems more quickly and more effectively is uncertain). And, most important, the principles of psychoanalytic therapy apply equally to women and to men.

Having considered a most controversial issue—women and psychoanalytic therapy—we now turn to a whole range of disputes about how one should un- derstand therapy and how one should do it. Changes in the understanding of therapy did not end with Sigmund Freud's original formulations about psycho- analytic therapy, nor with the changes he made after that, when he presented technical recommendations deriving from his structural model. We consider these further developments in the next chapter.

Co py

ri gh

t Am

er ic

an P sy

ch ol og ic al A ss oc ia ti on . No t fo r fu

rt he

r di

st ri

bu ti

on .