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This case illustrates a number of issues discussed in this volume and the clinical literature in general; straight or gay therapist; the traumatic loss of a partner to AIDS and its intrapsychic consequences; the manner in which various personalities experience and defend against what has come to be called internalized homophobia; working with an erotized transference; the role of sexualization in the maintenance of the self; and letting the transferences be our guide when faced with a very complicated patient. This case was originally for discussion by a panel, hence the clinical process is emphasized over my formulations though they come through in the way the material is handled and interpreted. The write up is a summary of the unfolding of the first 10 months of treatment, hopefully conveying how the patient and I got to the point of beginning to engage highly traumatized and disavowed aspects of his personality and the related challenges he poses in working more directly with transference material.
The clinical process with this patient centered around recognizing that the initial erotized transference was defensive in nature but also reflected the manner in which he managed considerable depletion, depression, and disavowed longings. Accepting, and working with the defensive transference, allowed the development of a more stable mirror transference and a quiet idealizing transference. Strong twinship elements are present as well. The mirror transference became the vehicle for accessing disavowed longings and the deeper, depleted, and vulnerable aspects of the patient's personality.
The patient is a 40-year-old man. A devoted bodybuilder, his appearance is quite striking given his considerable muscle mass on an average frame. He tends to present himself like a farmer or a laborer, often swaggering and lumbering when