As the number of women therapists increases, the study of the effects of the sex of the therapist on treatment becomes meaningful. Patients may choose, and mental health agencies may assign therapists of either gender, yet there are no guidelines for such pairing.
Meltzoff and Hornreich (1970), in reviewing the literature on sex-pairing in psychotherapy, conclude: “At present there is no clear basis for preferential assignment of a patient of either sex to a therapist of either sex. No statement can be made with confidence about the relative benefits of selected sex pairing with given types of patients.” More recently, a small, consistent body of literature has developed that permits some definitive statements about how patients differentially perceive, experience, and behave according to the therapist’s gender.
It is clear from the literature that patients and analysts are susceptible to sex-linked stereotyped ideas that critically affect treatment decisions. Given freedom of choice, patients almost invariably choose men as therapists (Fuller, 1963; Chesler, 1971), and a recent survey shows that the clients of women therapists are primarily women (Pendergrass, 1974). Two explanations are possible: patients are disproportionately attracted to male therapists or they actively avoid female therapists. Reasons patients give for seeking male therapists support both explanations: feeling greater respect for and confidence in a man’s competence and authority, feeling more comfortable with an relating better to men, discomfort with women, fear and mistrust of women as authorities, embarrassment about discussing sexual matters with women (Chesler).
There is an insufficient data base to determine whether agencies engage in the same kind of prejudicial coupling of patients with therapists as the patients themselves do. Broverman’s (1972) now classic study shows the sex-role stereotyped thinking of therapists who were asked to supply adjectives describing “a mature, healthy, socially competent adult man,” “a mature, healthy, socially competent adult female,” and “a mature, healthy, socially competent adult person.” Adjectives used to describe the adult male were in high correlation with those used to describe the adult person.
Why, then, are patients and therapists likely to prefer men as therapists and as models of human health? The answer lies partially in how it is that men and women are differentially perceived and experienced as therapists.
Much of the research on the different perceptions of men and women therapists employs the self-study (Tavistock) paradigm. The self-study group is defined as a collection of individuals whose primary task is to understand its own behavior. The stance of the leader (consultant) is non-directive and impersonal; he makes only interpretive statements, and these are directed towards and understanding of group process rather than intrapsychic dynamics.
Mills (1964) was the first researcher to investigate the preferred position of the male therapist in the group setting. He predicted that the passive role of the leader would elicit feelings of frustration and consequent aggression from the group members for their inability to have an exclusive relationship with the leader. Further, the non-responsive stance of the leader would have the effect of increasing solidarity among group members. Experimentation show, however that this effect is achieved only when the leader and members of the same sex, and not when they are of opposite sexes. Mills explained his results by postulating that the sex difference between the leader and group member intensifies the reciprocal desire for exclusive union. This intensification affects the group member by inhibiting expression of hostility towards the leader.
Perlman’s study (1978) describes and measures the way hostility to male and female group leaders is expressed. She found a greater incidence of overt hostility directed to men and a greater intensity of covert hostility directed to women. She studied as well the kinds of defenses which serve as a compromise form of expressing the aggressive impulse while at the same time protect against the danger of retaliation by the leader. She found that displacement and ignoring were the mechanisms utilized most often. Group members were also found to make statements more often to the female leader which served either to protect her or imply her inadequacy.
Other studies consider the therapeutic style and sex of the group leader as determinates on the behavior and feelings of group members. The Beauvais (1976) study of participants in self-study groups shows that women leaders who adopt a posture of non-responsiveness are perceived as contemptuous and distant while men leading groups in the same way are seen as friendly. A similar study by Wright (1972) finds that such women are seen as stronger, less warm, and less friendly than their male counterparts. Eisman’s data (1975) concurs, showing that men who perform with only minimal disclosure are rated as more congruent with their sex-role than either the high-disclosing men or low-disclosing women.
The data reveal strong and consistent interaction effects. When leaders adopt a posture of openness and emotional responsiveness, the women report more positive feelings about themselves and others in the group. When leaders assume a stance of low disclosure and non-responsiveness, the women become affectively negative towards peers. This evocation of negative affect is most intense when the nonresponsive leader is a woman. Independent of the therapeutic style of the group leader, members are more withholding and less self-revealing with women leaders than with men.
Fuller (1963), however, in studying the dyad counseling paradigm found contrary results. He reported that female therapists elicited more verbalization of feeling. Goldberg (1978) hypothesized that these discrepancies in findings might be attributed to perception of the therapist as an authority figure rather than as a source on nurturance and nourishment. Therapeutic styles associated with authority and nurturance were varied in both male and female therapists in the dyadic patient/therapist paradigm. Therapists who exhibited emotional response were seen as more nurturing; therapists who provided strictly interpretive statements were seen as authority figures. Men were always seen more as authority figures than women, regardless of their therapeutic style. Nonresponsive female women, regardless of their therapeutic style. Nonresponsive female therapists were seen as the least nurturing of all, even compared to the nonresponsive men who worked in the same manner.
These findings suggest that women are generally perceived more negatively than men in parallel authority roles. Insofar as a non-responsive therapeutic style is frustrating for the patient, it is conducive to a negative and regressive transference. Cultural expectation associates women with nurturance and emotional responsivity and men with authority, which is consonant with impersonalness and non-reciprocity. When a woman responds contrary to the cultural expectation, the frustration and resultant aggression arising from the unmet expectation is most intense. Patterns of displacement of aggression also differ for male and female leaders and group members. Nonresponsive leaders evoke aggression in women that is self0 and peer directed, and this is most pronounced where the leader is a woman. It seems that a mechanism is operating that protects the frustrating female therapist from aggression through a redirection of the negative feelings towards the self or other group members.
THE SOCIALIZATION PROCESS
Understanding these phenomena requires examination of how sex-role identification and stereotyping take place through socialization. The roles played by men and women are determined initially by the biological capacities of the sexes. Through bearing and nursing, the mother participates in a relationship of absolute primacy to the child. Exemption from such biological functions leaves men freer to specialize in activities requiring the establishment of viable relations outside the family.
The mother is the child’s earliest experience of nurturance and authority. Her food and warmth are vital to the child’s survival. But, as primary caretaker, it is also her role to socialize the child. This means that she is the agent of frustration and deprivation. As such, she becomes the target of the child’s easily sadistic impulses (Bayes & Newton, 1976). Freud refers to the girl’s
dread of being killed by the mother. It would seem plausible to conjecture that this anxiety corresponds to the hostility which the child develops towards her mother because of the manifold restrictions imposed by the latter in the process of training and physical care, and that the immaturity of child’s physical organization favors the mechanism of projection. (Freud, 1931, P. 90)
Horney emphasizes the feelings of inadequacy the boy feels in relation to the mother:
[He] feels or instinctively judges that his penis is much too small for his mother’s genital and reacts with the dread of his own inadequacy of being rejected and derided… [His] original dread of women is not castration anxiety at all, but a reaction to the menace of his self-respect. (Horney, 1932, P. 142)
Lerner (1974) agrees and suggests that the idealization of men and of the penis may be an effort to devalue the omnipotence and power of the maternal figure. Chasseguet-Smirgel (1970) contends that the child of either sex maintains a terrifying image of the mother, despite her objective goodness and kindness. Neuman (1955) and Slater (1966) both present anthropological and mythical material that suggest the power of the woman, the terror she inspires.
As primary caretaker, the position of the mother is intensely powerful. Her warmth is sustaining; her neglect or abuse can be destructive and terrifying.
The emergence of resistance to maternal authority is a developmental milestone for the growing child. The process is different for sons and daughters. For the son, the relationship changes from a relation based on power with mother dominant, to a relation based on sex-roles, where the son is dominant. For the growing boy, independence is a reversal of the original infant/ mother paradigm. If the transfer of power from mother to son is disturbed, prolonged subordination to maternal authority occurs. Societal scorn for such a disruption of the normal socialization process is strong. A woman in a position of authority over a grown man recreates a universal early situation. Insofar as the conflict is unresolved, the experience is likely to be regressive.
The situation is different for a daughter. She is not reinforced for assertive behavior, and the pull to separate from maternal authority is not so intense. Indeed, her socialization trains her to be comfortable in a subordinate position, so she is less likely to challenge authority of either sex. If a girl does attempt to assert herself over maternal authority, the struggle is between persons of unequal power but the same sex. Same-sex affiliation aids the process of identification, an added factor in female authority.
The oedipal period, in which the child experiences conflicts over maternal authority, is critical for the successful maturation. It is here that the father’s authority becomes most intense in censuring the child’s acting out of sexual longing for the mother. Feelings of hostility towards the mother are inevitable during this period. The son comes to understand that his childish love for the mother “has no real aim; it is incapable of complete satisfaction and this is the principal reason why it is doomed to end in disappointment and to give place to a hostile attitude” (Freud, 1931, p. 94). The daughter comes to understand that her mother “neglected to provide [her] with the only proper genital organ” (Freud, 1931, P. 97).
Successful resolution of this conflict for both boys and girls means that the child has been able to transfer authority from mother to father. The memory of the mother’s nurturing capacity endures, though, and she is now freely experienced as exclusively nurturing. Thus, for both the pre-and post-oedipal child, there is a role expectation for the woman to be nurturing and giving.
THE THERAPY PARADIGM AS RELATED TO THE FAMILY
The analyst/patient relationship is a recreation of the parent/child relationship. It was, in fact, this understanding which led Freud to posit the concept of transference, by which he meant that important and early feelings for the original loved-object are irrationally transferred onto the analyst.
The patient enters therapy with a complaint. The hope is that the therapist will be an agent for help or relief from frustrations. The child is in a similar position. A child is biologically dependent and learns to expect the parent to meet needs and relive frustrations. The dependent attachment the child forms to the parent parallels the transference the patient develops toward the analyst. Both patient and child experience a difference in power between self and the authority person in that the therapist or parent controls the sources of gratification and frustration which are beyond the reach of the ego’s control. The cure in therapy parallels the child’s emotional maturation. Patient and child learn appropriate skills by which to master sources of gratification so that they are no longer dependent on the authority figure. The patient’s analysis is terminated; the child becomes a mature adult. There is a reduction of conflict around the issue of dependency needs and around the consequent aggression as a response to frustration from an authority figure not meeting those needs.
THE FEMALE THERAPIST
Of course, analysis, like child rearing, is never quite problem-free. Patients sooner or later come to learn that the analyst is neither what they expect, nor, at times, what they want. The hope that all expectations will be gratified is a regressive hope. Analysts deviate from sex-role expectations. The mother association burdens the female therapist with the patient’s hope that she will be all-loving and all0understanding; she is, of course, unable to gratify this expectation entirely. Insofar as she is not bound by sex-role behavior, she may exhibit characteristics that are stereotypically male-appropriate. The reverse is true for men; they can be nurturing and motherly, rather than powerful and strong.
Why is it, then, that the woman who deviates from her expected nurturing mother role and exhibits male authority characteristics induces frustration and aggression, while the man who deviates from his expected authority role and exhibits nurturing mother characteristics does no evoke a similar response?
The socialization process defines the range within which the behavior or men and women may vary and still be considered appropriate to their sex. This process contains greater flexibility for the role model behavior for men than for women. Ideally, a woman embodies all the aspects of a good mother (warmth, nurturance, comfort) and none of the aspects of authority (power, dominance, control). A man, on the other hand, may have all of these characteristics: the nurturing ones from his experience of good mothering, and the aspects of authority from his experience of the reversal of the early matriarchy, where he assumes a position of male authority. In the transition, he does not lose the nurturant qualities of the good mother. Thus, the situation is created in which the man is dominant and in control of the female object on whom he was initially dependent and retains the ability to be nurturing. The woman is both initially and finally powerless and submissive.
A nurturing woman is seen as supremely fulfilling her expected role and is endowed with the qualities of good mother. Insofar as therapists are seen as authority figures they parallel the role of the father in the family. Because therapy is a regressive experience, both attributes are likely to be assigned to the therapist at various points in the treatment. Cultural expectation, however, does not permit the women to deviate from her nurturing role. When she is seen as doing this, the patient may become confused as to her sexual identity (Perlman, 1978, P. 19). Beauvais concludes:
If a woman behaves according to the principals of ideal authority, she will be accused of abandoning her sex role and being masculine. If she behaves according to the principals of any female power positions, by her very femininity she will fall short of the male authority ideal. As a competent authority she cannot meet the ideals of womanhood; as a woman she cannot meet the ideals of esteemed authority. (Beauvais, 1976, P. 43).
TRANSFERENCE
Differential perceptions and feelings regarding male and female therapists and group leaders have significance for the analysis of transference. Right and Gould (1977, P. 216) suggest that a “woman therapist in our culture may… find herself more often the target of negative transferences than her male counterparts.”
The experimental literature shows that the quality and quantity of the therapist’s communications determine in part the affective level of transference. Impersonal, interpretive statements that are made infrequently facilitate the negative transference. Spotnitz, from his clinical experience, sees that the analyst can control the affective level of a schizophrenic through selective communications to the patient (Spotnitz, 1969, P. 65-68). Treatment in the formative stages of the therapeutic relationship should proceed at a level of tension for the patient that is tolerable to his ego. For the severely disturbed patient, too much communication – which Spotnitz defines as ten to one hundred units of communication per session – creates more excitation than the patient can discharge’ too little communication – which Spotnitz defines as one or two units per session – likewise creates an intensification of resistance with relative inadequacy of motoric output, resulting in a regression too sever to be resolved in the course of the session.
The treatment is not restricted to the frankly psychotic patient. The stronger ego and the more highly developed defenses of the neurotic patient allow for greater tolerance for both minimal and maximal excitation. The idea that frustration produces aggression has been widely applied clinically, and finds its experimental equivalent in the studies comparing responsive and non-responsive leadership styles. The therapist who works with the negative transference attempts to limit the patient’s aggression within the confines of the treatment relationship.
The dynamic source of the aggression towards the therapist is the thwarting of the dependency expectations. The patient comes into treatment with preconceived notions about what the process will mean for him. He generally expects relief from his suffering and hopes to achieve a happier, more meaningful life. He also comes with preconceived notions about what the therapist will be like. These notions may be based on sex stereotypes, on part experiences with other therapists, or on his past history – all of which form the basis of the transference.
The gender-related aspects of transference, based on sex-role stereotypes, have been described. Male therapists are seen in more favorable terms, and as authority figures. Positive transference is, thus, more easily established with male therapists.
The emotionally non-responsive method of contact which facilitates a negative transference should take into account the gender-related aspects of the transference. Insofar as the non-responsiveness is consonant with male authority, there is a concomitant reduction of thwarted dependency needs. This is, patients expect fewer communications from male therapists and do not feel frustrated. Thus, a negative transference may be more difficult to establish.
The success of the analysis depends upon the analyst’s ability to resolve the patient’s resistance to verbalize thoughts and feelings. Cure may be considered to take place when the patient can comfortably tolerate all of thoughts and feelings. While the female therapist evokes more negative feelings, it does not follow that she will be able to evoke verbalization of these feelings. Observation of the defenses against direct verbalization of hostility towards the female therapist suggests the problem. Wright’s study indicates that disclosure is significantly reduced when the group leader is a woman. Perlman found female therapists to be protected against the overt expression of aggression. Beauvais found similar results and identified displacement as the main defense against verbalization of aggression towards women.
It is appropriate here to differentiate between defenses used in the group setting and those in the dyadic therapeutic relationship. The displacement of aggression away from the female therapist but still within the confines of the therapeutic setting is possible in a group because other objects are available for attack (i.e., group members). In one-to-one therapy, however, there are no other immediate objects on which to discharge aggression, and the elimination of displacement as a defense may have severe consequences. The patient who experiences aggressive impulses without avenues of discharge within the treatment setting may employ other, more regressive defenses to protect the object: he will turn his aggression inward and may become severely depressed, schizophrenic, or psychosomatic, or he will act out his aggressive impulses towards current life objects other than the therapist.
The caveat in understanding the relationship between therapist style and therapist sex is double-edged. The male analyst runs the risk of never adequately establishing a negative transference. The favorable position of the man may result in a deification of him. Wright and Gould (1977) conclude that it is the positive transference reactions that will need interpretation “in order to provide an opportunity for the more negative or disturbing underlying feelings to come into awareness (P. 216).” Conversely, the female analyst has less difficulty establishing a negative transference, but runs the risk that stereotyped notions about her fragility may inhibit the direct verbalization of the negative transference. Wright and Gould suggest that the defenses against direct verbalization of hostility towards a woman therapist means that “interpretations aimed at redirecting the negative feelings onto the therapist will have to be made more often by women therapists in order to provide sufficient opportunities for working through (P. 216).”
COUNTER TRANSFERENCE
Wright and Gould address the consequences of a woman being the object of more negative or distressing transference reactions than a male therapist:
She may find herself often feeling de-skilled, incompetent, isolated, or ignored, or valued only for her supposed maternal and nurturant qualities rather than her analytic competence (P. 216).
The patient who begins treatment with preconceived notions based on the se of the therapist will respond to the therapist in such a way as to induce feelings in the therapist related to the therapist’s sex-role identity (objective countertransference: see Spotnitz, 1969, P. 165). The analyst, too, may have stereotyped ideas about appropriate sex roles. If the analyst identifies with a particular role, moving freely with the emotional responses of the patient is limited.
The analyst’s self-perception, if sex-role stereotyped, may be viewed as subjective countertransference and as a countertransference resistance. The unwillingness to experience the full gamut of feelings induced by the patient prevents the use of the analyst’s own feelings as therapeutic leverage and interferes with the ability to understand the patient’s emotional history. Spotnitz enumerates some of the major countertransference resistances – the need to not feel hate, the need to be liked, the need to be right, the need to be good, the need to be better than the original object (Spotnitz, 1969, P. 172-173). We could add the need to be an authority figure, the need to be a nurturing figure, and more generally, the need to be an appropriate sex-role model.
When these countertransference resistances are examined, it becomes clear that some are sex linked. We expect to find certain countertransference resistances more often and more intensely in women than in men. The literature makes it clear that the woman analyst’s need to be supportive – derived from the patient’s expectation and her own sense of role-appropriate behavior – may interfere with her ability to set limits. If she frees herself from demands for role-appropriateness, she may find that patients and colleagues still value only her nurturant qualities, and she may feel that her competence is not being recognized.
Bayes and Newton (1976) describe a woman in a position of authority formerly held by a man. They contend that difficulties arise from two sources: her inability to exercise authority so as to adequately fulfill her obligations (countertransference resistance); and the inability of her workers to see her as adequately assuming leadership (transference resistance). They, as well as Fabian (1972) found that professional women see it as appropriate when they are subtly derogated or isolated on the basis of gender. Strass (1975) in studying co-therapy pairs, found that male and female therapists valued the female therapist for her ability to be warm and supportive; neither male nor female therapists regarded her as an authority figure for the patients. This author’s experience in co-leading a therapy group with a man was similar. The patients indicated that they wanted interpretive statements from the man and emotional concern from the woman.
Men are not exempt from identifying with role requirements. Patients need to deify their therapists; they rarely make objective judgments about the quality of the male therapist’s communications. The feeling induced in the therapist is that he is good, and, most often, right. Insofar as he uncritically accepts this induced feeling, the therapist will not be motivated to examine his own or the patient’s latent aggressive impulses. He may sail along in the analysis without proper critical evaluation of his functioning.
The patient’s transference resistance may also induce an appropriate countertransference reaction. This objective countertransference serves the analyst well in providing data which aid understanding of the transference. When, however, the subjective countertransference mirrors the objective countertransference, the analyst has difficulty separating induced feelings from feelings arising from the self. The socialization process aids in masking this differentiation by making subjective countertransference feelings ego-syntonic: that is, men expect to fee that they are good (and patients relate to them in ways that are appropriate to this expectation). Ego-syntonic subjective countertransference resistances are particularly difficult to resolve. Recent research and increasing interest in women in positions of authority have allowed women to begin to distance themselves from stereotyped notions of who they are and how they should be. But while they are beginning to feel more comfortable in positions formerly held only by men, it is not clear that there has been any real characterological change. Women may assume male positions without concomitant emotional, or even behavioral, change. Women have been seen as inadequate and continue to feel inadequate in positions of authority. One defense against feelings of inadequacy is to operate in a style that has given gratification in the past. Thus, women in authority may continue to operate in sex-role stereotyped ways. The danger in the therapeutic relationship is that a traditional model for sex-role identification may inadvertently presented to the patient.
Men have no yet had the benefit of a liberation movement to help them understand their sex-role stereotypes. However, their resistance to presenting a more varied and flexible model may not be so great, as their traditional position allows them to exhibit a wide variety of behavior without being seen as inappropriate.
The therapist’s resolution of his or her own sex-stereotyped resistances is important in the successful outcome of treatment. It means that the analyst is conscious of his or her intent and its effect, so that the model presented to the patient is deliberate. Insofar as the analyst is flexible in sed0role behavior, a wider variety of therapeutic change in the patient is facilitated. The analyst who has worked through his or her difficulties in being male or female can resolve similar resistances in the patient. Cure is freed from sex-role connotations and takes a broader meaning – mature, adult functioning.