Wood, H., 2003. Psychoanalytic Theories of Perversion Reformulated. Reformulation, Summer, pp.26-31.
Amongst the caseload of a psychotherapy service there will be a small proportion of patients whose principal difficulties are enacted within sexual relationships and often expressed through their sexual behaviours. CAT can sometimes play a useful part in the treatment of patients with disorders of sexual arousal, desire or response where the problem is psychogenic, but this is not the group that I will focus on here. The group of patients I am concerned with are those who present loosely with what DSM IV refer to as the "paraphilias" - what psychoanalysts think of as the perversions.
It is no coincidence that clinicians treating people with disorders of sexual functioning often draw on psychoanalytic ideas. For Freud, sexuality, sexual energy, and sexual preoccupations were at the core of the personality. Psychoanalytic thinkers have contributed extensively to the debate about the origins and vicissitudes of our sexual preferences and functioning. However psychoanalytic ideas, and particularly psychoanalytic ideas about sexuality, have also provoked controversy, dissent and criticism. Psychoanalysis as a treatment is often not available, affordable, or practical. Moreover, patients presenting with troubling or compulsive sexual behaviours who might seem like prime candidates for a psychoanalytic approach, are often so anxious, guilty and ashamed, that they shun the idea of an intensive and prolonged contact with a therapist. At most, they might be persuaded to put a toe in the water of psychotherapy, and to agree to a time-limited treatment. CAT offers a therapeutic approach which is engaging and acceptable to many anxious patients; furthermore, it lends itself to the incorporation of psychoanalytic insights within a brief, focussed therapy.
The Use of the Term "Perversion"
The term "perversion" is an unfortunate one, with powerful moral connotations. Definitions in the Shorter Oxford English Dictionary include "turning aside from truth or right; diversion to an improper use; corruption, distortion". There is no doubt that moral judgement is implied: there is a right way of doing things, and there is a perverted way of doing things. In the study of sexual behaviour many have therefore rejected this term in favour of the more neutral "paraphilia". However, the term "perversion" is still used and believed to have a clinical meaning within the psychoanalytic field, although its use has varied over the last century and between different schools of thought.
What it is that gets "perverted"? For Freud (1905) it was the sexual instinct, which became perverted from the normal aim of sexual intercourse, and the normal object of a heterosexual partner. Rather charmingly he suggests that perversions are sexual activities which "extend, in an anatomical sense, beyond the regions of the body designed for sexual union" or " linger over the intermediate relations to the sexual object which should normally be traversed rapidly on the path towards the final sexual aim" (1905).
The sweetener for this rather narrow view is that he considered deviations from this normal aim and object to be so common as to be virtually universal, so no one should be reproached for such behaviours:
"No healthy person, it appears, can fail to make some addition that might be called perverse to the normal sexual aim; and the universality of this finding is in itself enough to show how inappropriate it is to use the word perversion as a term of reproach". (Freud, 1905)
Clinically these "perversions" were acceptable as long as they only represented foreplay. If the behaviours became the exclusive source of pleasure, or had the characteristics of a fixation, or they were extreme (requiring the individual to overcome normal reactions of shame, horror, disgust or pain), then they were not only perversions but were pathological as well.
In retrospect it appears that Freud was well-intentioned. He clearly wanted to challenge the very narrow views of acceptable sexual behaviour which prevailed at the turn of the century. However, he also failed to see how immersed he was in that culture, and how culture-bound were his own definitions of normality and pathology.
Stoller (1977) recognised the potentially damaging consequences of confusing a moral position with clinical judgements of sexual behaviour, and suggested that we should look beyond behavioural descriptions to the underlying motive for the behaviour. For Stoller what becomes perverted is not the aim of heterosexual intercourse, but the ideal of sex as a vehicle for the expression of love. Stoller used the term "aberration" to refer to all those erotic techniques or constellations of techniques which were used as a complete sexual act and differed from a specific culture's avowed definition of normality. He reserved the term "perversion" for those aberrations which were habitual, preferred, necessary for full satisfaction, and - here is his emphasis - primarily motivated by hostility.
"We no longer need to define a perversion according to the anatomy used, the object chosen, the society's stated morality, or the number of people who do it. All we need to know is what it means to the person doing it." (Stoller, 1977)
This definition has some clinical appeal. Within this framework, compulsive womanising, where women were treated as objects of no consequence and the individual achieved a state of triumph and contempt, would at least be seen as more pathological than a loving homosexual relationship. However, it begs the question of how the motive for a piece of behaviour should be ascertained. Who decides whether and when a behaviour is driven by hostility?
Limentani (1986) emphasized that what is central to perversions is the perversion of truth. He proposed that the sexual behaviour represented a turning away from an intolerable "truth", such as the truth of gender difference in transvestism or the truth of generational difference in paedophilia. In Limentani's view, the perversion "attacks reality".
In a similar vein, Chasseguet-Smirgel (1985) emphasises the regression from genitality to anality, from the Oedipal universe of difference and laws of sexual union, to an anal universe in which everything is equal and the same, excrement is as exciting as intercourse, and there is a thrill in transgression, in breaking down barriers
"which separate mother from son, daughter from father, brother from sister, the erotogenous zones from each other" (1978, quoted in Welldon, 2002).
Even notions of "truth" are contentious, as demonstrated by recent discussions about the extent to which transsexuals have legal rights within their assumed gender. Transsexuals sometimes insist that "the truth" is that they were born with the wrong body. Psychoanalytically-oriented therapists (e.g. Hakeem 2002) might argue that "the truth" is that they suffer a burning discomfort with their given body.
Thus across the century "perversion" has been taken to refer to the perversion of the sexual instinct, the perversion of love, or the perversion of truth. All of these are problematic, but current, varied, usage of the term bears the imprint of these earlier ideas.
A more contemporary view, expressed by Harding (2001), is to consider, not whether sexuality is normal or perverse, but whether it is used expressively or defensively. Is sex used to enhance intimacy and the sense of self and other, or to protect the self or others from anxiety, or to disguise or erotise aggression and hostility? This latter view blends more comfortably with a CAT perspective, in which sexuality could be seen as integral to adaptive and functional reciprocal roles concerned with expression, acceptance and affirmation of self and others.
Psychoanalytic Theories of Perversion
a) Freud (1905, 1927)
Freud wrote his classic paper on Fetishism in 1927. In this he boldly states that the inanimate object which becomes a fetish represents the mother's penis. Freud argues that, for the young boy, the sight of his mother's genital confronts him with the possibility of castration. For some boys (and Freud admits that he does not know why this applies to some and not others), this castration anxiety is intolerable. The boy knows both that the woman lacks a penis, and cannot bear to know this. He can no longer sustain the belief that she has a penis exactly like his own, and so he invests in substitute - an object which is invested with the power to thrill and excite, which is often something glimpsed in the moments before he became aware of his mother's "castration" - shoes, stockings or underwear for example, or fur or velvet standing for the pubic hair. Thus intolerable anxiety is transformed into sexual excitement, and the fetish then becomes "a token of triumph over the threat of castration and a protection against it".
Freud holds that the fetish enables the boy / man to continue to relate to women as sexual objects as it endows them with a symbolic phallus and so they cease to embody the threat of castration. Furthermore, the fetish can be controlled and accessed by the boy / man at will.
"What other men have to woo and make exertions for can be had by the fetishist with no trouble at all." (Freud, 1927)
This may seem a rather fanciful account of the aetiology of a fetish and, as an attempt at explanation, it leaves many questions unanswered. It is nevertheless thought-provoking because in Freud's characteristic way, he offers a compelling clinical description and some of his ideas are still implicit in thinking about perversions today.
The first is the idea that the perversion, in this case the fetish, enables the individual to escape from an awareness of their own vulnerability (in Freud's words, the threat of castration). Instead of being at the mercy of an other who has the power to excite but also to punish and arouse anxiety, the individual invests an inanimate object with the power to excite, but an inanimate object which is entirely within his own control. Thus the individual escapes from anxiety and vulnerability and feels empowered, triumphant and in control. This is resonant with Stoller's (1977) more contemporary ideas about perversion and will be elaborated below.
The second is that the adoption of the fetish allows the preservation of the relationship to the object. Intimacy becomes possible because the terrors which that relationship might otherwise evoke have been negated. The woman, who might otherwise represent an unbearable threat, is made safe, since she still has a symbolic penis after all. There are parallels between this and Glasser's (1979) notion of the "core complex".
The third is that two completely contradictory ideas can be held in the mind at the same time: the reality of the woman's "castration" is both acknowledged and completely denied. This has subsequently been seen as a seminal paper because it introduced for the first time the idea of a split in the ego. We can both know and not know something simultaneously. Of more contemporary writers, Limentani (1989) is particularly concerned with the recognition and denial of psychic truths in perverse states of mind.
b) Stoller (1977)
Stoller's (1977) classic study of perversions primarily focuses on disorders of gender identity, transsexualism and transvestism, which would now be thought of as gender dysphoria. With persuasive clinical material, Stoller argues that there is always a trauma in the history of those presenting with perversions, but this trauma is not simply, as Freud suggests, exposure to the reality of sexual difference. In Stoller's view the historical trauma is some attack on the sexuality or gender identity of the developing child. He describes children of unambiguous biological gender being dressed or reared as members of the opposite sex by parents or parent-substitutes, or being ridiculed and bullied in relation to their gender identity.
The perverse act is then an act of revenge. The man who cross-dresses in order to obtain sexual excitement may appear to want to imitate and become like a woman, but actually this imitation is a caricature in which femininity is often parodied.
In the cross-dressing ritual, the secret of the man's masculinity is hidden, but at the end of the ritual he masturbates and ejaculates, reasserting his masculinity and mentally triumphing over those who have humiliated or denigrated him.
Thus Stoller argues that the perverse act serves as an apparent re-enactment of a traumatic past; the man repeats that which has been done to him, denies his masculinity, and assumes the identity of a woman. However this is a re-enactment in which history is re-written: this time the man is not left as the humiliated victim, but through sexualization this re-enactment of the trauma culminates in his pleasure and triumph.
Thus victim becomes victor, trauma becomes triumph, and passive suffering is converted into active revenge, usually in fantasy but sometimes enacted. This resonates with Freud's idea that the fetish enables the individual to escape from intolerable castration anxieties to a position of control and triumph.
Glasser (1979) locates the historical trauma at an even earlier stage of development than Stoller. In his view, at the centre of the psychopathology of those presenting with perversions is a constellation of feelings, attitudes and ideas which he calls the "core complex", rooted in early infantile experience. A major element of this is a profound longing for union, even fusion with another, the fantasy of a blissful state of oneness, in which the individual is made absolutely secure and all destructive feelings are contained and made safe, a "back in the womb" type experience. Whilst such longings are found in many loving relationships, in some individuals this fantasy evokes terror: a fear of permanent loss of self, annihilation, falling into a black hole. If the individual responds to this terror by retreat to a safe distance, he or she risks isolation and exposure.
Thus far this seems like an extreme version of the "porcupine's dilemma" addressed by the item in the Psychotherapy File "Either I'm involved with someone and likely to get hurt, or I don't get involved and stay in charge but remain lonely". This may be seen as a classic claustrophobic-agoraphobic dilemma. However, in Glasser's view, the anxieties aroused by this type of oscillation in core complex states are not just about being lonely or hurt, they are primitive, overwhelming terrors of annihilation and total abandonment.
Glasser was a contemporary Freudian, and like Freud, thought that the fundamental task of the ego was to guard psychic homeostasis, a steady state of well-being. Threats to this homeostasis evoke aggression, which aims to eliminate the source of the disturbance. In the core complex the threat of annihilation evokes aggression, yet if the individual were to destroy the exciting stimulus he or she faces an even greater threat, that of total abandonment by the object. Glasser argues that in perversions, the solution found to this dilemma is to sexualise the aggression. Aggression - the impulse to destroy the source of threat - is converted into sadism; the wish to destroy the object is converted into a desire to hurt and control the object. As in Freud's account of fetishism, a relationship to the object is preserved, by sexualization of the intolerable affects that would otherwise preclude an intimate relationship to the object.
Glasser observes that in the clinical histories of such patients there is often evidence of an early relationship with the primary care-giver who both used the child to meet their own narcissistic needs (thereby intensifying annihilatory anxiety and aggression), and neglected the child's needs (thereby amplifying abandonment anxieties and consequent aggression). He also reports histories of overt and excessive sexual stimulation by the care-giver. Thus environmental factors may have led to increased and intolerable aggression, acute fears of abandonment, or a predisposition to sexualise intolerable emotions.
Again, I think it is not necessary to adopt Freud and Glasser's rather biological model of instincts, organisms and homeostasis, to find the useful clinical insights in this view. In object relations terms, Glasser is highlighting the intense and primitive anxieties aroused by the promise of longed-for intimacy. The intense consuming merger which is desired is also seen as deadly and terrifying. In self-protection, aggression may be evoked which in turn threatens to destroy the very relationship which is so desired. How can this be made safe? By sexualising the aggression, and expressing it though ritualised enactments such as sado-masochistic sexual behaviours or "exciting" fights for example.
d) Rapid Oscillations Between Victim and Perpetrator
A common feature of clinical cases with these problems is the rapid oscillations between the "violated, humiliated, in danger" position, and the "violent, cruel, triumphant" position. In the course of a violent argument the individual may oscillate between these positions so rapidly that their position at any one time becomes blurred. In psychoanalytic terms this might be thought of as the alternating operation and failure of projective identification: the bad, attacking aggressor is temporarily projected into the other, then re-owned, then again evacuated.
In one CAT supervision session we had drawn a box, with this circular oscillation within it, and it was observed that this image resembled a washing machine:
The therapist then began to talk with the patient concerned about the "spin cycle", and this image became a useful focus in the therapeutic dialogue.
In cases treated by a small group of clinicians over several years, these psychoanalytic ideas have informed the construction of SDR's. The SDR can be used to map the way in which the patient uses sexualization to get from the painful vulnerability usually associated with the lower poles of the reciprocal roles, to a position of dominance, control, triumph, and sometimes active abuse associated with the upper poles of the reciprocal roles.
Glasser's ideas have alerted us to the danger of assuming that intimacy will be seen as comfortable and potentially good; for some patients it is associated with claustrophobic terrors, and is seen as both alluring and dangerous. Verbal or physical fights and sometimes life-threatening violent and sexual behaviours, may offer an apparent way of dealing with the terrors of intimacy and these sequences can be traced diagrammatically.
The "spin cycle" is a useful way of describing the oscillations between victim and perpetrator or abused and abuser, which can lead to dangerous and rapid escalation in some relationships.
CAT lends itself to plain-talking, uncritical naming of the elements of the self. The experiences of this client group may sometimes seem extreme and shocking and the use of sexualization may be a source of shame and embarrassment. The construction of an SDR is then particularly valuable in establishing a shared language for discussing these experiences and for acknowledging that there will inevitably be aggressive and vulnerable elements to the self. The SDR enables the patient to see how sexual behaviours are often rooted in feelings of fear, vulnerability or anger, and thus behaviours which might have seemed irrational, intense and driven may be given meaning and the sexual charge may be lessened.
There is widespread recognition that problems of sexual behaviour are very difficult to treat. It has been suggested that the sexualization provides a degree of gratification which means that the individual is reluctant to relinquish the behaviour. Some psychoanalytic theorists hold that the behaviour serves as a defence against unbearable "truths" which will be very difficult to face in therapy. Most psychoanalytic therapists would insist that it is only when the disturbed dynamics have been re-experienced and understood within the transference, perhaps repeatedly, that change can occur. What, then, can we hope to achieve in 16 or 24 sessions? Inevitably I think our aims must be modest, but not trivial.
With patients who are very frightened and ashamed, the first consideration may simply be that they have an experience of therapy which is containing, accepting, and does not deter them from seeking further help. From a therapeutic point of view, being able to own some of their own vulnerability and ask for more help may be progress.
In every such case treated with CAT that I have been involved with, some part of the process of naming, describing and drawing what was going on has reached the patient and offered some insight and relief. Having acquired this meta-perspective, some patients are able to interrupt automatic sequences of destructive behaviours. For others, this process may take longer. If an impulsive individual has more capacity to think instead of act then I think CAT therapists would concur with psychoanalytic therapists that there has been some progress. In Freud's language "Where id was, there ego shall be". In CAT terms, the Target Problem Procedure has been recognised and revised, and alternative strategies are now available to the patient to deal with painful emotions.
If we abandon Freud's libido theory for an object relations model, sexualization of the sort I have been describing becomes a means to an end, a way of dealing with intolerable feelings or positions in relation to internal or external figures. In CAT terms, it becomes a procedure, a way of dealing with the unmet needs or unmanageable feelings of the reciprocal roles.
If we were to include an additional section in the Psychotherapy File which specifically tapped these symptomatic forms of enactment, I wonder how many more of these patients would come to light. Sexualization might then be seen as equivalent to eating disorders or alcohol and substance abuse, as a distortion of a natural function as a means of dealing with intolerable psychic pain.
The following are some suggestions for these TPP's:
1. Feeling overwhelmingly empty and needy, or full of bad feelings, I overeat to fill the gap or to stuff down bad feelings.
2. When I feel disgust or loathing for myself, I deprive myself through starvation, or binge and vomit to punish and purge myself.
3. Feeling unbearably anxious, exposed, humiliated or confused in relationships, I use sex or cruelty to make myself feel strong, in control and on top.
4. When living feels too painful or I don't feel equipped for dealing with it I use alcohol or drugs to numb the pain and to try and make myself into the person I wish I could be.
As cognitive approaches to therapy gain momentum and popularity, it seems important that we do not become so focussed on the mind and thinking that we neglect the body and bodily forms of enactment. The use of CAT with people with eating disorders and addictions is relatively well-developed. Like eating or intoxication, sexual behaviour can be used as a means of self-expression, self-protection or self-destructiveness and can be central to some therapies and reformulations.
Chasseguet-Smirgel, J. (1985) Creativity and Perversion.
London: Free Association Books
Freud, S. (1905) Three Essays on the Theory of Sexuality.
In Standard Edition 7, and Penguin Edition,7, On Sexuality
Freud, S. (1927) Fetishism.
In Standard Edition 21, or Penguin Edition 7, On Sexuality
Glasser, M (1979) Some aspects of the role of aggression in the perversions.
In I. Rosen (Ed) Sexual Deviations. Oxford: OUP
Harding, C. ( 2001) Sexuality. Psychoanalytic Perspectives.
Hove: Brunner Routledge
Hakeem, A. (2002) Transsexualism: A case of the emperor's new clothes?
FRAME, The Newsletter for the International Association of Forensic Psychotherapy, Issue 6, 34-40.
Limentani, A. (1989) Between Freud and Klein.
London: Free Association Books.
Stoller, R.J. (1977) Perversion: The Erotic Form of Hatred.
Welldon, E. (2002) Sadomasochism.
Ideas in Psychoanalysis series, Cambridge: Icon Books
A fuller version of this article is due to appear in J.Hiller, W. Bolton & H. Wood (Eds.) Sex, Mind and Emotion. The Psychological Treatment of Sexual Disorders and Trauma. Karnac Books (to be published January 2004)
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Denman, C., 2003. Letters to the Editors: Psychoanalytic Perspective on Perversion Reformulated. Reformulation, Autumn, pp.4-5.
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Maria-Anne Bernard-Arbuz, 2013. Some reflections on the Malaga International CAT Conference "Mental health in a changing world". Reformulation, Winter, p.50.
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Fawkes, L. and Fretten, V., 2003. Two different presentations with Borderline Personality Disorder. Reformulation, Summer, pp.32-39.
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