The first and discomfiting task in commenting on this case is that one immediately confronts the challenge posed by a patient for whom the reality of the gendered body is problematic. To whom is one speaking? The disavowed Eloise has been banished. ‘Alex’, a name which does however suggest an ambiguity of gender, wants to be seen as male and referred to as ‘he’. The therapist believes that being addressed as a boy has been a ‘significant relief’ to him, and led to general improvement in his state. This is a very striking observation. It suggests that the dissonance between Alex’s sense of himself as a person and the perception of others was very painful to him. He is relieved when he can assert his sense of reality in opposition to what others think they see.
However we hear immediately of the feminine quality of his physical presence and that he and his family have decided against halting female pubertal development, so we are made aware of the female body simultaneously with its denial. Alex also lives in a world of other girls at his all-girls’ school (it is not so clear how he is addressed in the school context) and his friends are all girls.
We learn that Alex’s difficulties have been there for some years, but the context of their onset is not known. There is no early history to help our thinking, but we may be able to explore some ideas about the missing background from the clinical material. What we do know is that fatigue, poor sleep, anxiety and eating difficulties are all ongoing problems, his academic achievement being outstanding nonetheless. School looms large in that the previous term’s therapy was severely disrupted by exams, school life, and work experience. Alex’s capacity to assert the terms of engagement can thus be seen to set the scene within the therapeutic relationship as it does elsewhere.
The session presented follows the summer break. Alex starts at once as if welcoming the therapist to the renewal of their conversation. The therapist responds by asserting, perhaps combatively, that there is also evidence of her absence (‘we both looked tanned’) and drawing Alex’s attention to this. She then notes in surprise that she answered his question about her holiday destination, possibly feeling that she owes a reply, having inserted herself in the session so determinedly. Alex proceeds to a long account of his holiday, in which Dad and later Mum too feature as the insensitive ones, clearly presented as in the wrong, with Alex’s friends and implicitly, he assumes, his therapist, ranged on his side. We hear of Dad’s anger and Alex’s jealousy of the attention offered to his brother. We begin to sense the uncomfortable transference situation which Alex is, perhaps, inviting his therapist to avoid by joining in collusively with his moral superiority. However at this point his therapist continues to explore the family dynamics ‘out there’. This culminates in Alex being able to say that he hates conflict and to focus on what he finds difficult rather than continuing to analyse his parents’ failings. Therapist and Alex then work together to describe his identification with his accuser, both internal and external, and his pained sense of not being able to hold his ground. Alex moves from the complaint that Dad ‘shuts him down’ to a recognition that it is he himself who shuts down, unable to think or talk.
This part of the session seems to offer some clues to his chosen gender identity. He explains that arguing has been easier since he came out as ‘trans’. While mother and his insecure self are described as passive or passive-aggressive, father shouts and argues his case, and now that he is ‘Alex’ and male he feels that he too can engage in open conflict. We might see the cluster of symptoms referred to earlier as evidence of aggression turned against the self due to anxiety about expressing it in relationships.
There is an interesting sequence at this point in which the therapist proposes the idea that the ‘coming out’ narrative is itself a way of shutting down inquiry – much as a psychiatric diagnosis can sometimes function – and that it is in fact quite an effective way of controlling what is allowed to be said. The importance of the words used and of the way the patient attempts, through these verbal rules, to control the way he is seen by others is clear to them both at this point. Alex’s mood changes from both giggly and self-justifying to more serious. This thoughtfulness, however, is then dismissed by a laugh a moment later, and yet remains evident in his discussion of how his anxiety is freed when he can talk and ‘a massive weight’ is ‘lifted off his chest’. We can surmise that for Alex, the meaning of the breast development which he wants to flatten is extremely complicated.
In this central part of the session the therapist chooses to concentrate on Alex’s experience of feeling internally divided, one part joining in attacks on himself and the other part feeling silenced and belittled. The aggression is thus described, but the question of its expression in the therapeutic relationship is not yet referred to. This seems to be based on the therapist’s sense of Alex’s overall vulnerability, thus having to step carefully, perhaps particularly after a long break. However, Alex himself refers to the bullying and sheltering in a gang identity (the persecuted ‘trans’) that can be involved in claiming to be a victim of transphobia. Is he here inviting his therapist to be a bit bolder? I suspect so, since we hear next of his parents’ capacity to call his bluff, and assert that ‘trans’ does not say everything about him. It is thus not in reality a convincing umbrella explanation of all his difficulties. The therapist is clearly in touch with a real worry about ‘tipping things over’, but is also now able to include herself in an interpretation about the people who are silenced by Alex’s sensitivity.
At this point we hear again about Dad as the problem, when he expects Alex to make ordinary efforts to get on with life, and fails to appreciate the efforts he does make, and Alex now brings in mother as an ally. The therapist sees here a chance to explore the oedipal triangle in the family, and we might also observe the way Alex is trying to split his relationship to the therapist. While there is an understanding therapist who is expected to praise his efforts, there is also another who may be less impressed and more demanding of him. What is this new year of therapy, like the new experience of life in the sixth form, going to be like?
The triangle theme also brings alive not just the picture of friends seen as allies against annoying parents, but also friends felt to be rivals, echoing the sibling rivalry with his brother which had been touched on earlier. Who is to be the privileged ill one? Who is going to get parental attention, or indeed CAMHS care, now that his friend Sam is also being referred to the clinic? Once Alex’s object relationships come into focus, the whole internal family constellation and its transference being re-lived in relation to the clinic is now opened up for investigation.
Perhaps this feels too hot for both Alex and the therapist in the closing minutes of the session, as both now bring in different issues. The therapist finds herself talking about divided professional ideas regarding gender dysphoria, thus moving away from the relationship between the two of them to the wider CAMHS scene, perhaps drawn to keeping perspectives separate rather than risking the complexity of their interaction and hence potential conflict. Alex’s associations, meanwhile, move to life on the internet where he says he was at his happiest, asserting that when he was sad he was ‘not really me’. The happier direction he believes is the masculine one, while ‘the dark time’ (the hidden depression in this patient) is associated with puberty and the early days of secondary school. The time of growing into a woman was what was so fearful. Yet just at this point the therapist suddenly notes his deflated tiredness, signalling the failure of the manic solution which a masculine identity had seemed to offer him, and which is so seductive when separation looms. The rather speedy end to the session surely underlines just how problematic separating is.
It is astonishing and impressive to see how many things emerge in this one session. There is, I think, a sense of the therapy shifting gear after the period of patchy attendance and subsequent holiday. The therapist’s steady presence and careful listening has made a crucial impact on Alex, who can now perhaps trust her to survive his ambivalence.
How might we formulate what we know on the basis of this material about the nature of Alex’s inner world? I would suggest that behind the choice of a masculine identity is anxiety about femininity seen by Alex as inferior, passive, weak and depressed. His intellect (clearly a powerful one) is by contrast experienced as a male aspect of himself, able to have a voice and a position and exist in its own right, not needy and dependent. The eating difficulties suggest that Alex’s relationship to mother as the provider of food and indeed, at an infantile level, to mother’s breasts, is fundamentally troubled. To add to this, the nature of the splitting of the parents that becomes clear in the session perhaps has its origin at an early oedipal level. Mother’s strength – represented in bodily unconscious phantasy by the nipples that link babies to breasts and provide access to milk – is either experienced as absent, as it can be when mothers have suffered from post-puerperal depression, or has been attacked in phantasy. When puberty arrives, the girl has to work out with new urgency her relationship to the internal mother and its implications for her sense of her own body. This seems to have faced Alex with the problems of an internal image of a damaged feminine body from which he seeks escape. He has retreated to the pre-adolescent world in which girls and boys are not sexually interested in each other. As a boy, he does not seem to fancy his schoolmates, but rather to be with them as a boy–girl, a pre-pubertal child, but also something of an invalid, without the life force to engage with the turbulence of adolescence.
Therapy at this juncture provides a real opportunity for reworking Alex’s relationship to her/himself, and this session suggests that the work may be on its way.
Notes on contributor
Margaret Rustin is a child, adolescent and adult psychotherapist and an Associate of the British Psychoanalytic Society. She was Head of Child Psychotherapy at the Tavistock from 1985 – 2009. Since retiring from the NHS Margaret has continued to supervise child psychotherapists in many parts of the UK and to teach abroad. She has written about many aspects of child psychotherapy. Her most recent book, written jointly with Michael Rustin, is Reading Klein (The New Library of Psychoanalysis, Routledge, 2017).
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© 2018 Association of Child Psychotherapists
https://doi.org/10.1080/0075417X.2018.1427773