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PubMed2001

Irreducible subjectivity and interactionism: a critique.

The authors offer a critique of the privileging of subjectivity in psychoanalysis characteristic of what Hanly has called interactionism, with specific reference to the work of Renik. First, Renik's argument for the irreducible subjectivity of the analyst is explored and critiqued from a philosophical perspective. The need for and plausibility of a subtler notion of objectivity that takes into account the limitations of human subjectivity and that analysts can meaningfully pursue is defended. Second, Renik's 're-visioning' of psychoanalysis, which follows from his notion of irreducible subjectivity, is explored and critiqued. Renik's view of enactments is contrasted with a 'totalistic' perspective of countertransference that allows for important, finer conceptual distinctions. Renik's conceptualisation of countertransference enactments is characterised as a 'special case' of countertransference as a vice. Next, Renik's view of transference is critiqued for privileging the adaptive dimensions of transference, and for potentially sidelining archaic dimensions. Finally, Renik's conclusions and 're-visioning' of psychoanalysis are shown to follow from his modifying or jettisoning certain features of the analytic situation and process. These features and their implications are elaborated on. The conclusion outlines the extent to which the arguments presented can be extended to other advocates of interactionism.

Ego↗
PubMed2004

[Disorders of the self according to self-psychological theory: a case presentation].

OBJECTIVE: In this case report the classification of self-disorders and syndromes of self-pathology are reviewed. The self-structure of a male patient (Mr. R), who has a narcissistic personality, is defined, and the dynamics of the transference and countertransference in the psychotherapy process are discussed. According to self-psychology, the cluster of the self-disorder is divided into five subgroups: psychoses, borderline states, schizoid and paranoid personalities, narcissistic behavioural disorders, and narcissistic personality disorders. The syndromes of self-pathology, which arise as a consequence of a lack of empathy on the part of the self-objects in childhood, are classified into four groups: understimulated self, fragmenting self, overstimulated self and overburdened self. Mr. R is in his thirties, a single man who works in a bank and lives with his family. Because of Mr. R's definition of himself as lifeless and boring, his complaints about his feelings of emptiness, his fear of losing his cohesiveness and some hypochondriacal worries concerning his health, it can be thought that Mr. R has both an understimulated and a fragmenting self. In the first six months of his psychotherapy process, an idealizing transference was prominent. Mr. R perceived his therapist as a powerful and talented person and even a saviour. In the countertransference, "a saviour father imago" was enacted. It seems that Mr. R's childhood memories, which were related to his mother and father, are repeated in the transference-countertransference relationship.

Adult↗
PubMed1991

Variations in the analytic holding environment.

The concept of the holding environment has been used previously to characterize the treatment needs of severely regressed patients (Winnicott, 1963b). This holding of dependence is contrasted with the holding needs of narcissistic, apparently disengaged patients (Modell, 1976). The present paper considers the type of holding required by difficult, borderline patients. It is suggested that these borderline patients need a holding of their ruthlessness and rage, and also of analytic self blame. Clinical vignettes describe the holding of an anxiously demanding and of an overtly hateful borderline patient. The patient in a holding environment evokes widely divergent countertransference reactions. These range from maternal nurturing feelings with extremely dependent patients (usually those emerging from profoundly schizoid states), to feelings of annihilation with narcissistic patients and of deep self doubt, anger and destructive wishes with demanding or hateful borderline patients. In the treatment of narcissistic and borderline patients, the holding environment metaphor may help the analyst tolerate these difficult countertransference feelings. Clinical examples of each type of countertransference reaction are presented.

Adult↗
PubMed2004

Managing the chronic, treatment-resistant patient with anorexia nervosa.

OBJECTIVE: To describe the psychopathology of chronic, treatment-resistant anorexia nervosa, as well as a paradigm for its clinical management. METHOD: The foundation of the approach integrates clinical experience, empirical psychological findings, and a conceptual understanding of developmental and phenomenologic aspects of the illness. RESULTS: Elements of the management paradigm take account of the compensatory nature of illness chronicity. The inherent risks of treating these patients in the customary way are described, along with therapist countertransference that must be anticipated and effectively considered. DISCUSSION: The chronically ill patient requires a unique approach to care, one that minimizes the risk of iatrogenic effects of rapid weight restoration or failure to appraise the deleterious influences of therapist countertransference.

Adult↗
PubMed2003

Psychoanalytic supervision of the difficult patient.

Control cases from the broad group of non-neurotic but potentially analyzable patients appear with increasing frequency. The intense, complex transferences they develop place great stress on the psychoanalytic relationship and evoke marked countertransference reactions in psychoanalytic candidates, which reverberate within the supervisory relationship. Through application of a case study method, common themes emerge in the candidate-supervisor dyad: idealization of the supervisor and of classical technique, identification with the patient, parallel process enactments, difficulty maintaining the analytic frame, and the importance of concurrent training analysis. Classical supervisory techniques must be adapted to the "difficult" (non-neurotic) control case. Complex countertransference issues must be carefully addressed while maintaining the teach/treat boundary.

Adult↗
PubMed1993

Parapraxes in song recall: a neglected variable.

In addition to expressing themselves with verbal and nonverbal communications, and by the countertransference reactions perceived by analysts, patients also reveal their inner world of images and feelings specifically with music evocations. This paper presents an initial attempt to identify and classify some of the parapraxes produced in the evocation of lyrics and music by polyglot members of treatment dyads in two empirical studies and in private practice. There may be many others, particularly related to the music per se. This paper has focused mainly on the lyrics, the equivalent of the manifest content of dreams, which nonmusician therapists can learn to handle well. Instead, in the case of the musical latent content, some knowledge of music is necessary. Supervisors' songs were considered beyond the scope of this paper and will be addressed separately. Parapraxes in song recall signal unconscious transference-countertransference states in process at the moment of evocation.

Countertransference↗
PubMed2005

Psychoanalytic psychotherapy for severely disturbed borderline patients: observations on the supervision group of psychotherapists.

The authors describe the role of a supervision group of psychotherapists within a wider therapeutic field for severely disturbed borderline patients. The group concentrates on the transference and countertransference, seen according to Racker's distinction between concordant and complementary identifications. The implications of the prevalence of the complementary identifications over the concordant identifications of the therapists to their patients and the resulting regression to primitive defense mechanisms can be counterbalanced by the group's integrative functioning as receiver (1) of a variety of information about the patient, (2) of the therapist's attempt to understand and synthesize, and (3) of the therapist's countertransference reactions to his patient. The major discrepancies between the various conceptions of the borderline patients' psychic world and the appropriate therapeutic technique to be applied are also discussed, as well as the way the group filters the information and integrates the therapeutic thought. It might be said, therefore, that, in the "inpatient" phase of the individual psychotherapy, the group of psychotherapists functions, for the patient and the treatment, in a synthesizing context, as it provides the therapist with a space of integration for his split-off part of self and object representations, which the therapist makes use of for his patient.

Borderline Personality Disorder↗
PubMedDate not supplied

Autognosis rounds for medical house staff.

The authors describe the autognosis countertransference rounds for medical house staff at the Massachusetts General Hospital. At these rounds, which have been held weekly for more than a decade in the intensive care unit, countertransference phenomena and their relationship to medical practice are discussed. Methods that have facilitated the autognostic process are provided and highlighted by brief case examples. Participants at these rounds report that their self-awareness increases and the clinical care they provide often improves.

Adult↗
PubMed1986

Problems to anticipate in treating difficult patients in a long-term psychiatric hospital.

In a previous report, the authors identified four dimensions of patient pathology associated with treatment difficulty: withdrawn psychoticism, character pathology, violence-agitation and suicidal-depressed behavior. In a subsequent study, they linked these dimensions to patterns of countertransference. The present research extends the two prior reports by examining the relations of the patient pathology dimensions to staff members' dissatisfaction with four areas of treatment: interpersonal approaches, structure and control, quality of teamwork, and medication. The major findings are: withdrawn psychoticism primarily relates to dissatisfaction with interpersonal treatment approaches; character pathology entails dissatisfaction with the level of structure and control; violence-agitation poses particular problems for teamwork; and suicidal-depressed behavior is unrelated to dissatisfaction with any dimension of treatment. The authors propose that these various problems in treatment are, in part, mediated by patterns of countertransference which they described in the prior paper. These findings should help staff members to focus their attention on areas of treatment in which problems are bound to arise in work with different types of difficult patients.

Adolescent↗
PubMed1990

The barker: a synchronistic event in analysis.

The author uses a synchronistic event that occurred in a session with a patient to examine both the personal and archetypal symbolism of the transference/countertransference relationship. The archetypal images of the trickster and the dog are important in understanding the meaning of the event, and the author draws from these amplifications an understanding of how countertransference elements temporarily intruded upon the relationship. On the basis of the symbolism of the synchronistic occurrence, the author then discusses the rectification of these countertransference interventions and the results of such rectification with the patient.

Adult↗
PubMed1976

Sex bias in psychotherapy: a failure to confirm.

The authors examined the questions of sex-related countertransference and bias in psychotherapy by asking 65 male and 57 female experienced group therapists for clinical reactions to case materials of a bogus outpatient who was designated either male or female. They found that varying the patient's gender produced only small differences in the therapists' responses, and conclude that sex-related countertransference problems may not be as prevalent as had been previously thought.

Countertransference↗
PubMed1985

Medicolegal pitfalls in the treatment of borderline patients.

Patients with the borderline syndrome, although not always the sickest patients, often cause the most difficulty because of their intense and contagious affects, their often impulsive behavior, and the strains they place on the treaters' countertransference. The author explores the hitherto ignored area of medicolegal problems that often arise in treatment of borderline patients. Specifically, he addresses the issues of legal ignorance of the syndrome, the effect of dynamic processes such as splitting and psychotic transference, problems regarding limit setting and related management approaches, and problems arising from countertransference phenomena. He suggests approaches to these problems as well.

Borderline Personality Disorder↗
PubMed1987

The initial contract in the treatment of borderline patients.

The initial treatment contract with a borderline patient recognizes the patient's potential for destructiveness and builds in safeguards. The therapist's effort to protect the treatment mobilizes the patient's primitive defenses. The therapist must be prepared to respond to resistance to the contract by clarification, confrontation, and occasionally interpretation. Although countertransference reactions evoked by the patient's use of primitive defenses complicate the therapist's task of defining the necessary treatment frame, the therapist's recognition of countertransference responses can enable him to establish and enforce an appropriate contract.

Borderline Personality Disorder↗
PubMed1988

Supervision and privacy in psychotherapy training.

Supervision is an essential element of training in psychotherapy, and the issue of privacy in relation to the supervisory process is an important one. The authors examine the attitude toward privacy implicit in each of the two major models of supervision, the so-called didactic and countertransference models. They consider the ways in which supervision, particularly the countertransference model, and the use of audiovisual devices intrude on the privacy of the therapist and the therapy. Finally, they consider how the institutional and professional structures within which supervision takes place deal with the issue of privacy.

Attitude of Health Personnel↗
PubMed1977

Outpatient treatment of the aggressive offender.

The treatment of aggression in an outpatient setting has not been tried often mainly because of the nature and intensity of the countertransference reactions. However, with some modification of traditional treatment practices plus a careful monitoring of the countertransference successful treatment is possible without great danger to the therapist.

Adolescent↗
PubMed1977

Intensive psychotherapy for the psychiatrist's family.

A series of intensive psychotherapy cases of wives and children of psychiatrists reveals that the special problems they present may be divided into those at the onset of treatment, those in the process of the treatment, and special countertransference problems. Paradoxically, early recognition and acceptance of psychotherapy are a foremost problem involving the psychiatrist as father or spouse. During therapy, narcissistic injuries to the psychiatrist father or spouse and loyalty problems in the patient emerge as special problems. Countertransference revolves around peer relationships and "psychopolitics," as well as referrals of other patients.

Adolescent↗
PubMed1995

Interactional obstacles to empathic relating in the psychotherapy of narcissistic disorders.

Psychotherapy with narcissistic patients exposes therapists to a set of interactional pressures which threaten to disrupt the desired therapeutic stance of empathic relatedness. The therapeutic relationship is a field of unconscious mutual influence in which therapists' own narcissistic vulnerabilities are threatened by narcissistic patients' characteristic interpersonal style. A typical constellation of countertransference feelings and reactions is aroused, characterized by a temporary or chronic state of narcissistic symmetry between patients and therapists. In this relational state both patients and therapists unconsciously defend their respectively tenuous sense of self-esteem from the perceived threat posed by the other, using similar defensive narcissistic strategies. Unless this interactional narcissistic symmetry is diffused a therapeutic impasse ensues, which may jeopardize the therapeutic alliance. This potential is exacerbated in the case of those therapists with characterological narcissistic features, as they unconsciously require constant affirmation from their patients in order to enhance their deficient self-esteem. Enduring, understanding, and adaptively processing narcissistic countertransference responses facilitates the resumption of the desired empathic stance, characterized by an optimal condition of narcissistic asymmetry between therapists and patients.

Adult↗
PubMed2006

Learning about psychoanalysis combined with medication: a nonphysician's perspective.

When medication is at play in an analysis, the nonphysician candidate or psychoanalyst faces conceptual and practical challenges, as well as countertransference risks and opportunities. A psychologist psychoanalytic candidate describes the treatment of an analysand who underwent a gradual uncovering and worsening of obsessive-compulsive and anxiety symptoms; at twenty-one months, the analysand introduced the topic of medication. These developments brought to light transference and countertransference themes connected to the analyst's status as a non-physician candidate; conceptual and practical uncertainties about medication in the context of psychoanalysis; the complex meanings of, and indications for, medication in this case; and the ramifications of a nonphysician candidate's referring a patient to a psychiatrist psychoanalyst for medication while being supervised by another psychiatrist psychoanalyst.

Adult↗