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PubMed2003

The management of affect storms in the psychoanalytic psychotherapy of borderline patients.

Affect storms are a frequent complication in the psychoanalytic approach to borderline patients. The descriptive, psychodynamic, and structural characteristics of these storms are explored, and the verbal, nonverbal, and countertransference manifestations that permit the formulation of interpretations under such conditions are described, as are the interventions required to maintain the treatment frame as a precondition for an analytic approach. The principal theoretical formulations regarding the affect pathology of borderline patients are reviewed and related to a proposed interpretive approach. An apparently opposite development, the utter absence of emotional developments in the sessions, is examined, and its defensive function of avoiding affect storms is explored. Clinical case material illustrates the proposed approach to these storms, and clinical evidence is given to support the approach, which centers on systematic analysis of the primitive internalized object relations of these patients in the transference, the use of countertransference analysis without countertransference communication to the patient, and the repeated restoration of technical neutrality in the service of protecting the treatment frame.

Acute Disease↗
PubMed1984

An example of self-analysis.

The literature on self-analysis indicates that it is a desirable process to cultivate postanalytically for continued self-growth, analyzing countertransference problems, and dealing with symptoms or problems of living that might arise after formal analysis is completed. A number of techniques are described, the choice of which is probably dependent on the personality of the individual who wishes to pursue self-analysis. I describe an episode of self-analysis occurring near the end of the analysis of a woman who aroused in me an unusual degree of positive feeling, at least part of which can be considered countertransference. After she had aroused negative feelings in me, she was able to deal in an affectful way with strongly repressed impulses, actually acted out in early childhood, to steal from her mother. This stimulated dreams in me that allowed me to work out guilt for hostility to my mother. A dream representing stealing her purse altered long-standing compulsive thoughts I had known meant guilt to my mother. The self-analysis was not undertaken to deal with a countertransference problem, but arose out of it to deal with a symptom, or old conflict, 25 years after the completion of formal analysis.

Adult↗
PubMed1999

The impact of psychoanalytic theory and a two-person psychology on the empathising analyst.

Traditionally 'empathy' has been viewed from the perspective of a one-person psychology and 'the facts' discovered via empathic understanding have been thought to reflect accurately what the patient was experiencing, ideally uncontaminated by anything coming from the analyst. In contrast to this position, the author argues that the analyst always actively influences what he discovers empathically. Specifically, the analyst's theoretical biases always shape what he empathically understands. The contributions of Owen Renik and, to a lesser extent, Irwin Hoffman are critically examined, with a focus on how their two-person perspectives shape the analyst's ability to empathise. Their clinical stances, which emphasise the role of corrective emotional experiences and countertransference enactments, are compared to what the author calls an 'integrated stance', which attempts to integrate elements of one- and two-person psychologies while retaining interpretation as primary in bringing about change. It is concluded that the techniques advocated by Renik and Hoffman potentially restrict empathic understanding in two ways. First, they take positions that limit the development of regressive transference reactions. Second, because they de-emphasise monitoring countertransference urges, they actively facilitate more frequent countertransference enactments, which then may not be interpreted as fully as by the analyst working from an 'integrated stance'. Clinical examples are used to illustrate differences between these two stances.

Adult↗
PubMed2002

The ghost in the group room: countertransferential pressures associated with conjoint individual and group psychotherapy.

Conjoint individual and group therapy is a commonly used, effective psychotherapeutic treatment. The relationship between the conjoint therapists significantly influences the treatment. This article examines countertransference dilemmas of the group and individual therapists arising from the real and fantasied conjoint relationship. Case examples illustrate specific countertransference dilemmas. Therapists are encouraged to consider the possibility of difficulties with each potential conjoint treatment. Consultation and supervision are recommended to help the conjoint therapists identify and manage countertransference pressures.

Adult↗
PubMed1994

The eroticized transference: a tool for the reconstruction of childhood sexual trauma.

In this paper the eroticized transference is seen as a tool to reconstruct the childhood trauma through the patient's material and the corresponding countertransference in the therapist. The theses is presented that the eroticized transference is an indicator of the existence in the life of the patient of childhood sexual trauma, often unbeknownst to him or her and that it can be of great value in the reconstruction of the experience. The reason it has not been used may lie in our tendency to deny the reality of incest and in the propensity of the analyst for counterresistance in response to these patients. Between avoidance and acting out lies the opportunity to use the countertransference response of the analyst as a catalyst and to reconstruct the traumatic events through the patient's material and the corresponding response in the analyst. Two cases, a male and a female, exemplify the use of transference and countertransference for recollection and reconstruction of the traumatic childhood experience.

Acting Out↗
PubMed1975

The psychoanalytic impasse.

In the study of impediments to the success of psychoanalysis as a treatment method, the character structure of the analysand has received the most attention. Psychoanalysis has come to be used for the treatment of an ever-widening range of psychopathological states, and the analysts have become confronted with a greater incidence and variety of clinical situations which can develop into therapeutic obstacles. Whether the psychoanalytic impasse will become a therapeutic stepping-stone or an obstacle to treatment often depends upon the emotional response of the therapist and his resultant behavior. Accordingly, there has been a heightened interest in the study of countertransference. Some therapists equate the psychoanalytic treatment of patients with severe character deformations with "wild" analysis and therefore feel needless guilt and anxiety when they attemtp to treat patients who suffer from them; thus they increase the likelihood of their becoming therapeutic obstacles. We have considered the psychoanalytic impasse as an inevitable aspect of the analytic sequence and discussed countertransference reactions in this context. Technical complications resulting from adverse countertransference reactions are examined both in terms of the patient's provocations and responses in the analyst. Among the analyst's responses, three were emphasized: (1) helpless fellings which represent the patient's helplessness and vulnerability; (2) rage reactions; and (3) profound anxiety reactions. The patient's need to construct and environment similar to the early traumatic environment within the analysis can become a very difficult situation for a therapist. The resolution or at least understanding of these interactions becomes equivalent to the lifting of infantile amnesia, a step which has been considered the essence of psychoanalytic resolution. Thus, adverse reactions can become keys to the gaining of fundamental insights, permitting the analytic process to continue its inevitable course.

Anxiety↗
PubMed1992

The analyst's transference imagery.

The countertransference is a concept whose meaning has changed considerably. Freud and his followers regarded it as a negative reaction in the treatment which the analyst had to master. Since 1950 and Paula Heimann's pioneering paper, the countertransference has been understood and used more positively and has come to be seen as an essential tool for achieving completeness in the work of analysis. In line with this approach, this paper describes a countertransference reaction which has proved to be useful. It concerns the appearance of images of houses in the analyst. These houses correspond to important experiences revived by the analysand's material. The emotional content of these images links up with an identical content in the patient. An interpretation based on this experience has an enhanced therapeutic strength and effect. The paper concludes with a case study and a theoretical discussion of the phenomenon.

Countertransference↗
PubMed2006

The analyst's excitement in the analysis of perversion.

The author believes that unconscious sexual excitement in the transference and countertransference is an especially problematic aspect of the analysis of perverse character pathology and that perverse sexual gratification deserves a more prominent position in the clinical theory of analyzing perversion than that which has been assigned tacitly through analysts' routine focus on the defensive and destructive dynamics of perversion. He presents clinical material from the analysis of a perverse patient that illustrates the role of excitement in the transference perversion established in this analysis; and he asserts that gratifying perverse enactments occurring in the transference perversion can appear not only as conscious or unconscious excitement in the transference but also, at times most clearly, as the analyst's excitement. The author suggests that using a clinical theory that supports the analyst in understanding his excited responses as perverse countertransferences--i.e. evoked excitement complementary to the sexual component of a perverse transference--will assist him in locating and thinking about gratifying, perverse excitement in the transference where it is most usefully analyzed. Finally, he discusses some of the reasons why analysts might deny, suppress or otherwise avoid perverse countertransferences and in so doing contribute to sustaining perverse resistances.

Adult↗
PubMed1990

Nonphysician psychotherapist-physician pharmacotherapist: a new model for concurrent treatment.

In the last century the mental health field has vacillated between a biologic versus a psychologic model of the mind. Only in the last two decades have proponents of both views calmly discussed their virtues and limitations. As a result, clinicians have begun to promulgate the concept of an integrated, concurrent psychotherapy and pharmacotherapy. While this debate has raged in the psychiatric field there has been a parallel proliferation of nonphysician mental health professionals. Most of these mental health clinicians come from training programs steeped in the traditions of a psychodynamically based treatment that occurs within the interpersonal context. Today more and more of these clinicians compete for the increasing population of those seeking relief. The result of these two movements has been the introduction of a unique form of treatment in which a patient sees two therapists. In this triangular treatment, the pharmacotherapist prescribes medications and the psychotherapist provides the interpersonal therapy. In order for all practitioners to participate in this form of triadic treatment they must appraise themselves of not only the historical debates preceding this therapeutic concordance but of the transference and countertransference potentials. Some patients can have idealizing, magical, and nurturing transferences toward either therapist in the triangular relationship. Other patients can be narcissitically wounded, with a negative devaluing response toward either therapist. Paralleling the patient's transference distortions are the therapists' countertransference reactions. These can run from the omnipotent identification with the patient's idealization to the devalued, distancing response toward oneself or the patient. If these distortions are not checked they can intrude on the treatment, acting out the patient's internal split self-object representations and ultimately sabotaging treatment. Successful attention to transference and countertransference phenomena can lead to an enhanced treatment in which the biologic and psychologic treatments have a synergistic effect. Only then will we be capable of fully evaluating and researching the positive and negative effects of combined psychotherapy and pharmacotherapy with two different therapists. The outgrowth of this research will be improved patient care by enhancing our capacity to identify those patients and therapists who are good candidates for this triangular treatment relationship.

Combined Modality Therapy↗
PubMed1989

[The impact of perceptual stereotypes in indications for psychoanalysis].

Results of several experimental studies concerning the practice of selecting patients for psychoanalytic therapies are presented. The convergent findings strongly suggest that the indication for psychoanalytic therapies are heavily stereotyped and are dependent upon stimuli that do not result from communicative interaction with the patient. These facts are confronted with the psychoanalytic understanding of the role of countertransference during the indication process. Countertransference and stereotypes person perception do not necessarily contradict each other. It is proposed that countertransference reactions in this situation are partly a consequence of compatibility stereotypes vis á vis the patient which are quickly and unconsciously formed and which are afterwards differentiated and extended but also rationalized on a conscious level.

Countertransference↗
PubMed1986

The merits and problems with the concept of projective identification.

This paper reviewed the merits of and problems with the concept of projective identification. On the negative side, lack of universal meaning of the term was cited. Personal countertransference receives little regard, while an isomorphic reading of patient feelings may be used to gratify omnipotent symbiotic analyst and patient fantasies. On the positive side, the concept offers a framework that can lead to deeper understanding of difficult therapeutic situations. It helps the analyst process and contain distressing feelings and eschews interpretation that can be destructive to the analytic process. Proper use of projective identification should engage the patient's ego rather than foster passivity and merger wishes. Case material was presented which illustrated problems with and merits of the concept. Personal countertransference, especially therapeutic omnipotence, was shown to receive insufficient attention. The important role of complementarity in projective identification was illustrated in the treatment of depression, a disorder which can offer difficult treatment resistances. In conclusion, the concept should not be used as a justification for analyst omnipotence and avoidance of countertransference responsibility. The concept, however, can lead to a deepening of the analytic situation if it is used with caution and respect for the patient's separateness.

Countertransference↗
PubMedDate not supplied

Responses to creativity in psychoanalysts.

A discussion of "Concerning Transference and Countertransference" by Harold Searles, M.D. Searles's study, written and rejected for publication in 1948-49 contains six original contributions to these subjects. They include the definition of determinants of transference in the immediate analytic interaction, the role of projection in transference and its evocation by the analyst, its basis in actual traits of the analyst which are exaggerated, and its expression as an effort to elicit confirmatory responses. Searles also details the fullness of the analyst's participation in the therapeutic interaction and the constructive usage of countertransference reactions. The negative responses to Searles's creativity prompt the thesis that every professional has a wish to both accept and destroy the innovator and his innovations. Factors include envy, a dread of inner turmoil, impingements on countertransference defenses, and deviations in the conditions of training analysts. These reactions are paralleled by refractoriness to the patient's unconscious creativity and efforts to cure the analyst. The manifestations of these hostile reactions and the innovator's responses to them are discussed.

Attitude of Health Personnel↗
PubMed1993

A candidate dreams of her patient: a report and some observations on the supervisory process.

In this paper we argue that a candidate's reporting of her countertransference dream (CTD) in supervision, and its subsequent discussion, had two consequences. Firstly, it enabled the candidate to find her way out of an acute therapeutic impasse with her patient. Secondly, it provided important experimental and cognitive learning for the candidate, especially in the area of countertransference management and in the maintenance of her analytic work ego. This successful use of her CTD allowed her to enhance her self-analytical skills, with particular reference to her ability to monitor her own affective responses, and subsequent interpretive formulations, to her patient's contributions to the on-going transference-countertransference dynamic. Our findings concur with those of other authors who suggest that CTDs occur at conflict-laden times in analysis. In addition, we postulate a link between the parallelism phenomenon and CTDs as adaptive responses to internal and external challenges in the context of control analyses and supervision.

Adult↗
PubMed1996

[The ethics of psychoanalytic technique].

The ethic of psychoanalytic technique which goes back to Freud and emphasizes the importance of anonymity, abstinence, neutrality and the central role of interpretation is subjected to a critical examination. The author traces the changes that have taken place since Freud and proposes a new ethic of psychoanalytic technique. Proceeding from the theory of object relations, Treurniet stresses the symmetrical relationship between analyst and analysand permitting both to assume a "meta-position" in order to reflect on the analysis material. The author further suggests that, beyond the projections of the analysand, the analyst should be open to his own subjectivity, as this openness is the key to the essential feature of analytic procedure, the enactment of countertransference. Finally, Treurniet reformulates his advocacy of a non-intrusive, affirmative attitude on the part of the analyst, a spontaneous willingness to "fall into the analysand's trap", an ability to oscillate between acting-out and introspection, to live out countertransference involuntarily and finally to incorporate the non-ideal into his conscience. These rules of technique must be controlled not only by the conscience and the countertransference of the analyst, but also--apart from intervision and consultation with collegues--by the analysand himself, whose opinion of the analytic situation the analyst should ask for.

Countertransference↗
PubMed1996

Invisible victims: battered women in psychiatric and medical emergency rooms.

Violence against women by their male partners is widespread and infrequently identified as a causal factor in multiple physical and psychological problems of female patients in medical and psychiatric settings. Three main countertransferences that interfere with accurate identification of battered women are described: (1) counter- identification, (2)countertransference rage, and (3) countertransference helplessness. Battering men and battered women are found in all levels of society, although younger, lower income, less-educated men who have observed parental violence in their own home are at higher risk of abusing their spouses. Additionally, antisocial personality disorder, depression, and/or alcohol and drug abuse increase the risk of male violence in the home. Contrary to popular belief, the husband-to-wife violence is usually motivated by his need to control her rather than a result of his loss of control. Battered women show no consistent prebattering risk markers, except for a history of parental violence in their family of origin. Violence against women by their male partners is a serious public health problem that has not been adequately addressed by the medical and psychiatric professions. Myths and clinical realities of battered women are described and detailed recommendations for clinical inquiry and evaluation of level of danger are given.

Adult↗
PubMed1997

Clinical and developmental dimensions of hate.

Bridging concepts of aggression, affect, and attitude, hate emerges during the process of separation-individuation concurrent with ego development and persisting intrapsychic conflict and fantasy. Rage precedes hate developmentally, though later the two are amalgamated both developmentally and clinically. Hate is the negative pole of ambivalence and is a component of all self- and object representations and object relationships. When excessive and unmodulated, hate interferes with object relations and personality development. Paradoxically, hate may also subserve adaptation and personality organization. Transference hate is often a greater problem for the psychoanalyst or psychotherapist than is transference love. Transference hate threatens the analyst's narcissism and neutrality and tests the analyst's tolerance and patience. The patient's intense hate is often experienced as a direct assault on the analytic relationship and the analytic process. Countertransference hate and the need to defend against it are of great clinical importance. Because it runs counter to analytic ideals and values, the analyst's hatred of the patient may be denied, minimized, rationalized, enacted, or vicariously gratified and may occasion great resistance to analytic self-scrutiny. Countertransference hate is often an unrecognized determinant in cases of analytic and therapeutic impasse. A classic contribution by D.W. Winnicott to the recognition and elucidation of countertransference hate is reevaluated.

Adult↗
PubMed1998

The concept of enactment and theoretical convergence.

Classical analysts have recently become interested in the constructive use of countertransference. Some have extended the traditional conception of transference enactment to include the analyst's countertransference enactments. That is, the analyst may unwittingly actualize the patient's transference and, together with the patient, live out intrapsychic configurations. Awareness and interpretation are likely to occur only after there has been a transference-countertransference enactment. Some classical analytic writers have concluded that such experience may be both inevitable and a productive means of achieving analytic goals. This point of view corresponds closely to positions long expressed by interpersonal psychoanalytic contributors, thus signaling a trend toward a partial convergence of these two historically divergent theories of therapeutic action.

Countertransference↗
PubMed2001

The "ER" Seminar: Teaching Psychotherapeutic Techniques to Medical Students.

The challenge of teaching good communication skills and psychotherapy to medical students was addressed through development of a clerkship seminar that stressed the practical application of psychotherapeutic techniques to the difficult and/or psychiatric patient. Clinical vignettes from television programs such as "ER" were used to illustrate encounters with extremely emotional or personality-disordered patients. Students also examined the dynamic meaning of these encounters, their own countertransference, and their ability to tolerate emotional interchanges with such patients. In addition, the vignettes were used to examine and apply Buckman's model for breaking bad news to patients who have undergone a significant loss. Seventy-two third-year medical students participated and completed pre- and post-seminar questionnaires to assess their knowledge and attitudes toward psychotherapeutic techniques. Students significantly improved in knowledge of countertransference, boundary setting, and how to break bad news. Attitudes toward breaking bad news and recognizing strong countertransference also improved. Some differences in post-seminar knowledge and attitudes were found between male and female students.

Journal Article↗