The PANY Bulletin

Psychoanalytic Association of New York
Vol. 40, #1, Spring 2002

Consummated Mother-Son Incest in Latency
A Case Report of an Adult Analysis
by Howard S. Rudominer, M.D.

(November 19, 2001)
Discussant: Austin Silber, M.D.
Reporter: Yujuan Choy, M.D.

Dr. Rudominer presented the first detailed psychoanalytic case report of an adult male with a history of severe physical, verbal, and sexual abuse including consummated incest with his mother during latency. The patient, Mr. D., underwent five years of successful analysis with Dr. Rudominer.

Dr. Rudominer gave several reasons for presenting this case. Consummated mother-son incest is a very rare occurrence, and such cases have never been reported in detail in the past. In addition, these patients may be more analyzable then has previously been thought. Finally, the resistance on the part of the analyst and the strong countertransference reactions in these cases may account for the sparse existence of clinical case reports of mother-son incest.

Mr. D was a thirty-five year old, unhappily married father of two, employed as an insurance salesman, with a history of marijuana and cocaine abuse, who sought treatment because he wanted help in resolving his indecision regarding whether or not to leave his wife (Mary) for another woman (Ann) with whom he was having an affair. Mr. D. had a long history of multiple affairs—sometimes two or three concurrently, and a history of bizarre sexual practices that included a compulsion to have intercourse with multiple sexual partners on a daily basis and sadistic behaviors of tying his partner, Ann, to the bedpost. Mr. D. also enjoyed exhibitionistic sexual activities such as playing with Ann's vagina in restaurants, having sexual intercourse in public places or having her perform fellatio on him while he was driving.

Mr. D had an extremely traumatic childhood. He was the youngest of two sons, ten years apart, born to a mother who was verbally, physically, and sexually abusive to him until he was eleven when she died, and to an alcoholic father who frequently beat him until he was fourteen, when his father died. Mr. D. initially went to boarding school after his mother's death, then was sent to live with a wealthy uncle for a short time. Although Mr. D. felt that his uncle was a cold man who had also sent him to boarding school, his uncle had provided him tutoring at the age of twelve for his illiteracy, put him through school, and left him with a large inheritance when the patient was seventeen. Mr. D was thrown out of several boarding schools and military academies for repeated unruly behavior and fighting. At the age of sixteen, he went to live on his own in New York City. His older brother did not allow Mr. D. to move in with his family.

Mr. D. graduated from a New York City prep school, where he began to use alcohol and drugs heavily. He attended college at night for two years. He worked for a butcher for ten years and had a long affair with his boss's wife, who was fifteen years his senior. The boss and his wife were his surrogate parents. Mr. D at this point met Mary, whom he married. He had continued his affair with Beth until early into his analysis when he became serious with a third woman, Ann.

This was the state of Mr. D's life when he began therapy. Dr. Rudominer realized that Mr. D. had serious underlying character pathology, and after several months of psychotherapy, decided that psychoanalysis was his best chance of resolving his conflicts. The patient initially began to uncover the enormous abuse he had suffered as a child, the severity of which was initially unknown to Dr. Rudominer. He would rub his hands and complain of feeling cold, experience intense anxiety on the couch, and reported fragmented images of him touching his mother's breasts and vagina, and of his mother touching his penis. These images did not surface again for another year and a half into analysis.

For the first year and a half, the analysis concentrated on Mr. D's acting out behaviors and explored his turbulent relationship with his wife Mary. His relationship with Ann gradually became much more constant and loving, with less sadomasochistic and exhibitionistic sexual behavior. Mr. D also gradually stopped his drug use, gave up all of his other affairs, and became much more successful at work.

A year and a half into the analysis, Mr. D. again began rubbing his hands and complaining of feeling cold. He remembered his mother giving him baths and "touching his balls" while washing him. For a month or so he struggled with memories of beatings from his father and of his mother's failures to protect him. The pain of these memories was so intense that he was tempted to run away from analysis. Mr. D. continued to recall painful memories. He once knocked over his father's beer by mistake and got hit in the face as a result. He was also knocked off a chair by his mother when he was four or five and had to get stitches on the head.

That year, his first dream upon resuming analysis after Dr. Rudominer's vacation was about urinating on a woman. He remembered how mortified he felt when he occasionally had to urinate on the street, and his mother would hold his penis.

Mr. D's resistance to analysis increased over the next several months, and he began to claim that he could not pay for the divorce and the analysis together. Dr. Rudominer made several interpretations of Mr. D.'s resistance, including Mr. D.'s fears of recalling/re-experiencing painful memories, his wish to be analyzed for free, and his wanting to be taken cared of by Dr. Rudominer the same way his uncle or women in the past had cared for him. After these interpretations, Mr. D. became less fearful and less resistant in the analytic situation.

Later that fall he had a nightmare about a hairy monster emerging from the ocean, and Dr. Rudominer interpreted it as possibly representing his naked mother. For the first time, Mr. D. vividly recalled his mother sucking on his penis. He would then recant his statements, and became extremely guilty and doubting the accuracy of his memory. Dr. Rudominer pointed out to Mr. D. that his past behavior of having Ann perform fellatio on him may have been a re-enactment of these memories. Mr. D.'s mother had been naked when she gave him the baths and he remembered rubbing her vagina. He was very frightened by these images, but new memories kept emerging. He recalled touching his mother's vagina and wanting to stick things in it, and having watched his mother masturbate when she bathed him. Mr. D. began to connect these memories with his pattern of degrading women. Dr. Rudominer pointed out that the degradation might have been secondary to the excitement, guilt, and shame that he experienced, and this interpretation evoked memories in Mr. D. of watching his mother masturbate while being forced to touch her vagina. A very important session followed:

"I am very nervous. I woke up in the middle of the night screaming from a nightmare in which I was yelling, 'Mommy, don't.' It was horrifying, scaring the shit out of me. Part of me doesn't think they can be real, but if I am imagining them, then why? I've been wanting to get back to drugs again to get away from my thoughts of my mother. It is a funny feeling to have the anxiety so strong that I want to go back to cocaine again. . . . When A says no to sex, or when I want something badly, I feel alone and rejected like from my mother."

Dr. Rudominer interpreted to Mr. D., that although it was terrifying and horrible, he enjoyed the closeness to his mother, and that the sexual contact was better than feeling rejected and alone. He replied:

"I used to get into trouble in school so my mother could come to get me. I wanted to be stimulated by her. Wow! Stimulated is a funny word to use. . . . I guess I really wanted to be close to her. . . . Strange. . . . My thoughts went from my mother taking me home to peeing on me and giving me a bath. The picture is getting clearer of me lying down in bathtub and her standing over me. [Short silence] I don't know. Is it real?… It now goes further to my mother sticking things in my ass. I have to be very sick to think of things like that! Mothers don't do things like that, and if she did, she must have been very mean."

Dr. Rudominer pointed out how very disturbed his mother must have been.

Over the weeks, further recollections emerged: of his mother urinating on him, kissing his penis, sticking carrots, cold from the refrigerator, into his ass and making him lie on her bed. Dr. Rudominer brought up the connection between these memories and his earliest feelings in the analysis of being cold, lying on the couch. Dr. Rudominer was very supportive at this time. Mr. D. felt helpless, dependent on his mother, and had craved her attention. Mr. D went on to say:

"I was thinking about what you said about my not being able to accept how fucked up my mother was and how she is still alive inside of me. . . . I am thinking of being excited by my mother and things I've done for excitement, like being exposed in public, fucking in Central Park, going out with women where they and I were naked under our coats. I just had the image of my mother holding my prick while I was peeing and her making me walk around wearing just panties and a coat."

Two years into the analysis, Mr. D.'s divorce with Mary was finalized. He related his delay in the divorce to his need to internally "hold" on to his very disturbed mother, and equated his divorce with his mother's death. He began to analyze his fear of being alone, and connected it with feeling alone and empty after his mother's death. He felt helpless, loss, and alone at this time, and his fear of abandonment by Dr. Rudominer was also intense as he desperately wanted the guidance that he had never gotten from either parent. He again contemplated quitting analysis, but persevered. After nearly two years of analysis, he was feeling relatively content for the first time in his life. He was doing well financially, seeing his children regularly, living happily with Ann, and committed to his analysis. However, he was frightened of a loving relationship, and pondered whether he loved Ann.

Over the succeeding several months a negative transference developed, marked by intense distrust which started with a vacation Dr. Rudominer had taken several months earlier and exacerbated by a new lock in the office. This mistrust was interpreted as a re-enactment of the distrust of his parents, and a defense against further recollections of his traumatic past.

During this time, Mr. D. remembered his mother's sadistic behaviors towards him. He recalled her making him sit on a hot radiator, touching his penis to the radiator, tying him up in her bed, and giving him cold enemas. After that session, the patient began experiencing hypnoid and dissociative states, which felt foggy and not real. These states might have represented a re-enactment of what he experienced during the actual traumas, and served as a defense against overwhelming anxiety, guilt, and murderous rage. Mr. D. was frightened of the intensity of his murderous rage. He began to recall more of the tying up incident. He remembered his arms and legs bound together and himself face down on the pillow, unable to see. His mother stuck something into his rectum before the enema: Mr. D recounted: "While I was crying, my mother was rubbing my legs and rear end. I remember being on a rubber sheet … the more I talk about it the more certain I become of what actually happened."

Mr. D had a history of rectal bleeding from anal fissures since he was a teenager. That year on Mother's Day, he developed a bad case of hemorrhoids. He wondered if his persistent rectal problems had been caused by his mother.

That fall Mr. D. had a new upsurge of anxiety in the face of increasingly vivid recollections of new material: this time of his mother sitting on the edge of the bathtub and forcing him to lick her vagina. He confessed to feeling very lonely, and asked if they were going to have an appointment on Thanksgiving. Dr. Rudominer felt that it would be too much for Mr. D. if his longing for Dr. Rudominer was interpreted at that time.

Three years into the analysis, more graphic memories began to emerge that were extremely upsetting and disturbing to Mr. D. "It seems unbelievable. Am I making it up? Can it be real that my mother and her friend Mrs. C. did things to me together? I remember going there a lot. They tied me up. . . . " He recalled them touching him, sticking things in his rear end, and laughing. Mr. D. also recalled his mother parading him around in a bra and panties for Mrs. C, and reported the feeling of hating his mother and being glad she died.

As the fourth year began, memories continued to emerge, such as his mother sticking a cold popsicle into his rectum, and again he rubbed his hands in the session and felt very cold.

In the middle of the fourth year, Mr. D for the first time recalled actual vaginal penetration of his mother. He remembered being naked in his mother's bed to warm up. Mr. D. reported images of his mother sitting on top of him, as though they were having sex, and Mrs. C. watching and laughing, which made him feel very dirty. He recalled watching them lick each other and getting a beating afterwards, with the threat that they would kill him if he told anyone. His recollection went black after this, but in the ensuing weeks more memories emerged about sex with both his mother and Mrs. C. He found these memories very disgusting, but also stimulating. Dr Rudominer pointed out how confusing and frightening the excitement was, and how overwhelmingly guilt-ridden it left him. Mr. D. became terrified in the transference, and feared that Dr. Rudominer would either sexually assault him or beat him.

Over the next year, a great deal of working through of these traumas and of analyzing the transference took place. The patient married Ann, and became increasingly successful at his job. However, for reasons that was in part resistance and in part reality of finance, Mr D. decided to terminate his analysis about a year and a half after the emergence of the memories of penetration and about five years since the analysis had begun.

A few weeks before termination, Mr. D dreamt that he was back in the nineteenth century, and in charge of a fort that was being attacked by Indians. He felt confident and opened the door. He grabbed an Indian who had a bow, arrow, and spears. He was standing in the middle of a stash of guns. He was able to kill the Indians and felt that he had won. He thought an Indian got him with a spear, but he shot the Indian before he hurt him. Mr. D. interpreted this dream as a termination dream and felt good about it. In the next-to-last session, he dreamt that his ex-wife was killed in a plane crash, and wondered if this represented the ending of all his problems.

In the last session, Mr. D. expressed intense and disparate emotions. He felt strong, proud, and excited, but also strange, about terminating the analysis. He became tearful when he talked about how important the analysis had been to him and how difficult it was to give it up. He felt that Dr. Rudominer had been a "mother, father, brother, everything, at different times." He was proud that he had allowed himself to trust someone so thoroughly. He felt better able to look objectively at his life, and understood that self-analysis was a lifelong goal.

Dr. Rudominer told Mr. D. how remarkably well he had done in the analysis, and how he really had enjoyed working with and helping him. Mr. D. left owing Dr. Rudominer a couple of thousand dollars. He had said he would pay in installments, but stopped after several months. Dr. Rudominer felt that Mr. D. needed to owe money to keep his symbiotic and sadomasochistic tie with Dr. Rudominer in the transference. Pursuing the balance aggressively would have re-enacted the trauma with his mother.

Although a number of general principles might be gleaned from this case study, Dr. Rudominer noted some limitations of the case. First, data was sparse during the first year and a half of Mr. D.'s treatment because Dr. Rudominer did not keep lengthy process notes and had difficulty remembering details from many years ago. The case was also highly focused on the abuse experience and neglected some other important trends in the analysis. For example, several transference issues, such as Mr. D.'s homosexual feelings towards Dr. Rudominer, were never fully addressed. Dr. Rudominer noted that his strong countertransference might have prevented him from fully analyzing Mr. D.'s narcissistic and perverse conflicts.

Dr. Rudominer mentioned that at times he became so overly involved in the particulars of the abuse experiences that he temporarily overlooked dynamically important intra-psychic aspects of these experiences. Dr. Rudominer had struggled with whether the specific details of the abuse actually occurred, and ultimately chose to validate Mr. D's incest experience. Dr. Rudominer is in agreement with Kramer, Shengold, and Margolis that verifying the incest experience with patients is crucial to a successful analysis. However, he disagrees with Levine's position that uncertainty is inevitable, and it is not the analyst's task to decide whether or not the sexual abuse existed. Dr. Rudominer believes that not verifying the incest represents a re-enactment by the analyst, and can represent the analyst's own unconscious wish not to acknowledge the incest.

This case shares some similarities with other mother-son incest cases reported in the literature. As noted in similar cases, there is a tendency to doubt the existence of the incest experience on the part of the patient as well as the analyst. Mr. D's case also began with the mother's obsession of the child's bowel function. Moreover, excessive sexual stimulation of the child can lead to learning disabilities, as demonstrated by Mr. D's inability to read until he was tutored at the age of twelve. Steele has noted that men who have been sexually abused in childhood are more physically abusive and more sexually inconsiderate toward their female partners than others. This was evident in Mr. D's sadomasochistic sexual acting out behavior.

Mr. D.'s self-destructive tendencies are in accord with other analysts' (Shengold, Margolis, Loewald, Gabbard) observations that these patients have a pathological development of the superego, splitting from extreme need for gratification to need for self punishment.

Many analysts (Gabbard, Shengold, Margolis and Rothstein) emphasize the profound narcissistic conflicts that inevitably arise in mother-son incest. Mr. D. was not an exception as he also had marked narcissistic conflicts, and acted as if ordinary social rules did not apply to him. Regardless of the narcissistic gratification, the experience is nevertheless always profoundly traumatic to the child.

Although significant narcissistic, masochistic, and perverse conflicts were present, Mr. D. was a basically neurotic man suffering from intense guilt and castration anxiety. Despite problems with trust, he is capable of developing long-term meaningful relationships and possesses an unusual ego strength that allowed him to survive his abusive childhood. One of Mr. D.'s ways of coping with his trauma is abuse of cocaine, which prevented him from remembering the incest. Soon after the analysis began, the cocaine addiction subsided and was replaced by memories of physical and sexual abuse. These recollections of sexual abuse coexisted in the analysis with hypnotic states, which is a well-documented defensive mechanism in other sexual abuse cases.

A unique factor in this case is that Mr. D. was able to tolerate a rigorous analytic approach, and underwent a more complete analysis then that of other mother-son incest cases that had been previously reported. Although Mr. D. ended his analysis prematurely, with several transference issues not fully addressed, Mr. D. nevertheless benefited a great deal from the analysis, resolving many of his conflicts, and demonstrating significant structural changes in his character.

Dr. Silber began by noting the overwhelming power of the presentation, and the intense resistance such material would arouse in the therapist. It led him to the realization that a patient he had treated and written up over 20 years ago had actually had an incestuous relationship with his mother, but he had not conceptualized it as such until he read this paper.

He remarked on the fact that bodily sensations were centrally involved in the beginning of the lifting of repression, and wondered whether repressed physical sensations may usurp the bodily awareness of the patient on the couch and initiate the return to consciousness. Images and phrases emerged also, but the meaning of these experiences did not emerge until later, after the analyst formed an alliance, interpreted his acting out behavior and helped him learn how to differentiate between feeling, thinking, and acting, which is essential in treating patients such as this. He noted that analysts who see bizarre acting out behavior in a generally neurotic patient should be alert to the possibility of early trauma by disturbed parents.

Dr. Silber noted that self-object boundaries are unstable in these situations, and it is essential that the analyst point out the nature and severity of the parental disturbance to help the patient separate his reactions from his mother's and understand that he, as a child, would have been unable to resist.

Dr. Silber commented on an earlier version of the paper, in which Dr. Rudominer had noted that in subsequent follow-up sessions the patient had re-repressed the way that Mrs. C. had abused the patient. This phenomenon raises interesting questions about the nature of repression.

Discussion from the Floor Dr. Anna Burton said that Dr. Rudominer's paper had helped her understand one of her patients whose mother had abused him by keeping him as an appendage and engaging in mutual stimulation with him. That patient was also able to learn in the course of analysis. Dr. Burton said that she learned from Dr. Rudominer's paper that some of her patient's symptoms were expressions of his memories of abuse. The patient often created odors in the consulting room, reflecting the experience of anal play with his mother.

Dr. Leonard Shengold said that he had never meant to stress the benefits of child abuse. There may be good if the patient later turns passive into active, but overall the experience is devastating. He did feel that in cases in which there was extreme emotional deprivation, the abuse at least provided some relief from the experience of total neglect. Dr. Shengold asked what was meant by consummation of incest. He said regarding the issue, "did it really happen?", that important as it is, it is not our job to validate, but to listen, to leave it up to the patient. The patient is the one who needs to become certain. It takes patience and tact, and sometimes you just can't tell if abuse has occurred. He also asked Dr. Rudominer if he thought the patient's rage might have led to the end of treatment.

Dr. Jules Glenn spoke of a study group in which two of the patients presented reported uncle-child incest. Neither patient was certain that the incest had occurred and both wanted to learn about it from the analysts, who were also uncertain. Dr. Glenn was impressed by Dr. Rudominer's saying that if the analyst doesn't take a stand he allows the patient to continue his obsessive thinking. Dr. Rudominer acted as if it had occurred. Dr. Glenn asked Dr. Rudominer to comment on why he thought it did occur and why he thought the patient was uncertain.

Dr. Rudominer's Reply Dr. Rudominer agreed with Dr. Silber that it is important to help the patient distinguish his feelings and thoughts from the mother's. He thought that Dr. Shengold was right about the rage, that they never got to the rage in the transference, and that it may have been one of the reasons the patient left treatment. He responded to Dr. Glenn that doubting is ubiquitous in these patients, but that he could not answer why this is so.

Editor's Note: The Reporter for this meeting, Dr. Yujuan Choy, is a psychiatric resident who is currently participating in the NYUPI Fellowship Program.