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PubMed1994

Dual therapy: personality change in the therapist while working with patients.

This paper promotes a recognition that it is often necessary for therapists to engage in an extended therapeutic process of working on their own personality difficulties which arise in the course of treating various patients in order to help them more effectively. Although gradually it has become increasingly accepted that countertransferences frequently occur in the work of all therapists, such impediments to the therapeutic process almost inevitably have been considered to be overcome as soon as the therapist becomes aware of them. The focus of this paper is not on countertransference per se, about which much has already been written. Rather, it emphasizes the necessity for two parallel therapeutic processes which I have termed "dual therapy" in order to facilitate the benefits of psychotherapy.

Adult↗
PubMed1994

The analyst's participation in the analytic process.

The analyst's moment-to-moment participation in the analytic process is inevitably and simultaneously determined by at least three sets of considerations. These are: (1) the application of proper analytic technique; (2) the analyst's personally-motivated responses to the patient and/or the analysis; (3) the analyst's use of him or herself to actualise, via fantasy, feeling or action, some aspect of the patient's conflicts, fantasies or internal object relationships. This formulation has relevance to our view of actualisation and enactment in the analytic process and to our understanding of a series of related issues that are fundamental to our theory of technique. These include the dialectical relationships that exist between insight and action, interpretation and suggestion, empathy and countertransference, and abstinence and gratification. In raising these issues, I do not seek to encourage or endorse wild analysis, the attempt to supply patients with 'corrective emotional experiences' or a rationalisation for acting out one's countertransferences. Rather, it is my hope that if we can better appreciate and describe these important dimensions of the analytic encounter, we can be better prepared to recognise, understand and interpret the continual streams of actualisation and enactment that are embedded in the analytic process. A deeper appreciation of the nature of the analyst's participation in the analytic process and the dimensions of the analytic process to which that participation gives rise may offer us a limited, although important, safeguard against analytic impasse.

Adult↗
PubMed1994

Psychoanalysis as a lifeline: a clinical study of a transference perversion.

Case material from the analysis of a fetishistic cross-dresser is reported. The evolution of a transference perversion and treatment impasse, in the form of the recalcitrant symptom of anal flatulence, is described. The patient's contrasting needs to cling perversely and addictively to the analyst, on the one hand, and to provoke an acting out of the countertransference, on the other, are placed in the context of his dread of rejection and potentially suicidal reaction. The author argues in favour of offering psychoanalysis as a lifeline, but with the condition that the psychoanalytic setting and boundaries are maintained and that gratifications are denied. Limited but precise interpretive psychoanalytic work in the transference was maintained. The relatively good outcome is explained in terms of the provision of safety, survival of the analyst and avoidance of countertransference acting out, which, in the author's view, represents an implicit and mutative transference interpretation, the specific factor in bringing about psychic change. This enabled the patient to recognise and accept the analyst as a 'new' object and, as a consequence, to question and reject his idealisation of the anal universe that he inhabited.

Acting Out↗
PubMed1994

Farewell to the objective analyst.

The objective analyst is one who can stand outside of any given situation and make neutral observations, providing his or her countertransference feelings are in hand. The argument against such objectivity offered in this paper is that the activity of analysis involves both prejudice, i.e. one's pre-set ideas, and participation, i.e. a necessary and inevitable change in oneself. Therefore we all see things a bit differently, and we are all effected differently by what we see. Such a view of analysis forces us to insist upon limiting its practice to the analytic setting as well as calling for a recognition of our own subjective states which go beyond countertransference and encompass our whole selves. Since we are never context-free we must recognise that our interpretations are never able to be limited to one fixed reading and so the exchange between patient and analyst is always open and continuous.

Adult↗
PubMed1996

An adopted analysand's transference of a 'hole-object'.

The author describes the vicissitudes of the transference and countertransference in cases where the internal object transferred by the patient on to the analyst is experienced by the former as non-existent. A case history involving a 'hole-object' of this kind is presented, the patient concerned having been adopted at the age of six months and having the fantasy that she did not exist before her adoption. The hole-object is created by the patient to defend against psychic suffering and aggressive drives towards the object. A careful distinction is made between the hole-object, which is defined in terms of its non-existence, and the absent object, the 'psychic hole', the melancholic object and the bad-breast feeling, all of which exist or have existed at some time. The author describes the 'double transference', in which she represented both the idealised albeit well cathected adoptive parents and the disavowed, abandoning biological parents; in the latter case indifference took the place of love and hate in the transference. The analyst in this situation must in the author's view interpret his transference role as a hole-object so as to confer existence on this object and make it representable, and for this purpose a vital role falls to the countertransference. The split between the abandoning and the adopting aspects of the parents can then be resolved, giving rise to a single identificatory parental image.

Adoption↗
PubMed1997

The unbearable agony of being: interpreting tormented states of mind in the psychoanalysis of sexually traumatized patients.

This article focuses on the clinical importance of the disturbing transference-countertransference matrix in the psychoanalysis of patients whose ego development was decisively influenced by early, traumatic sexual abuse. Dissociative defensive operations and "automatic" identifications are emphasized in accounting for the sadomasochistic and other characteristic features of the "traumatic" transference-countertransference ambiance. Two clinical vignettes depict the analyst's need to take his or her own disturbing experience as an object of analytic examination, while illustrating how "here-and-now" transference cues are used to interpret the patient's efforts to cope with overwhelming, traumatized states of mind.

Adult↗
PubMed1976

On becomine a psychiatrist: discussion of "Empathy and intuition in becoming a psychiatrist," by Ronald J. Blank.

Using the data from Blank's (1976) description of his clinical efforts with his first patient, selected tissues on becoming a psychiatrist and psychotherapist are explored. Considered among the motives for entering this profession are opportunities for the therapist to projectively identify into his patients, and to introjectively identify with and contain his patients' psychopathology. The relationship between empathy and intuition on the one hand, and projection and projective identification on the other, is also studied, as is the need for the application of the validating process in confirming all so-called empathic and intuitive responses on the part of the therapist. Counter-transference influences on the experience and use of empathy and intuition are also investigated. The development of therapeutic misalliances and framework "cures," the distinction between transference and nontransference, the constructive elements contained in essentially countertransference-based interventions, the mastery of countertransference difficulties, and the choice of insight-oriented versus noninsightful therapeutic modalities are discussed.

Attitude of Health Personnel↗
PubMed1976

Psychological unevenness in the academically successful student.

Among students seen is psychoanalytic psychotherapy, there is a group who present the paradoxical clinical picture of great academic success alongside of quite primitive features in other aspects of their psychological functioning. This article offers an early developmental formulation of this aspect of these students. A clinical description of these patients is presented, including the observation that for each the early mother-child relationship seems to have been characterized by a predominant focus on maternal needs. A case history and summary of therapy of one of these students is discussed. Aspects of the mother-child relationship are explored by means of historical data, memories, and most important, through various transference and countertransference manifestations. The nature of this early relationship is then discussed in terms of the work of Donald Winnicott and Masud Khan. Finally, an overview of therapy is presented along with a discussion of some forms of resistance and some countertransference problems that often arise in the course of therapy with such students.

Achievement↗
PubMedDate not supplied

Psychiatric consultation with regard to requests for euthanasia or physician-assisted suicide.

The objective of this article is to describe the practice of psychiatric consultation with regard to explicit requests for euthanasia or physician-assisted suicide in the Netherlands. Written questionnaires were sent to an unselected sample of 673 Dutch psychiatrists, about half of all such specialists in the Netherlands. The response rate was 83%. Of the respondents, 36% (199 of 549) had at least once been consulted about a patient's request for physician-assisted death. The annual number of such psychiatric consultations is estimated to be 400 (about 4% of all requests for physician-assisted death). About one in four consultations is initiated by another psychiatrist. Consultants were mainly asked to assess whether the patient had a treatable mental disorder (68%) or whether the patient's request was well considered (66%). Assessment of the influence of transference and countertransference was less frequently sought (24%). Of the 221 consultation cases described, 67 (30%) ended in euthanasia or assisted suicide, whereas another 124 (56%) did not. In most, but not all, cases where the patient's request for physician-assisted death was refused, the respondent had judged that the request was not well considered or that the patient had a treatable mental disorder, or that the decision-making was influenced by transference and countertransference. We conclude that psychiatric consultation for patients requesting physician-assisted death in the Netherlands is rare, as in other countries. The issue of psychiatric consultation with regard to requests for physician-assisted death, especially in patients with a physical disease, needs to be further addressed.

Adolescent↗
PubMed2006

The caregiver's perspective on existential and spiritual distress in palliative care.

There is a paucity of research relating to how palliative caregivers conceptualize, identify, and provide for spiritual and existential domains of care. Focus groups comprising experienced palliative care providers participated in three semistructured 2-2.5 hour interviews, which were transcribed and subjected to thematic analysis. Eight themes were revealed: conceptualization of spirituality; creating openings; issues of transference and countertransference; cumulative grief; healing connections; the wounded healer; sustaining a healing environment for the caregiver; and challenges and strengths for the spiritual and existential domains of palliative care. While the spiritual and existential domains were variously conceived by experienced care providers, their significance for both patient and caregiver was affirmed. Transference and countertransference issues and the "wounded healer" concept were considered fundamental to effective care. Strategies for promoting therapeutic depth discussion were suggested and the importance of self-awareness and staff support emphasized.

Adult↗
PubMed2005

[Psychoanalytical aspects regarding etiology and understanding of schizophrenic psychoses].

The author -- specialized in Psychiatry and Neurology as well as a Psychoanalyst -- reports her experience during some decades of treating patients with schizophrenia in greatly different hospitals and institutions. Many examples demonstrate that psychoanalytical knowledge and recognizing psychodynamic connections can essentially contribute to understanding and treating psychotic patients. From the multitude of psychoanalytic theories on the etiology of schizophrenia some aspects are demonstrated, mainly those regarding their use in practical work. Some of them are: ego-disturbance, the psychotic symptom as a defence mechanism and the problem of countertransference. Regarding the ego-disturbance some examples show that usually not all ego-functions are impaired. Thus, cognitive functions may not only frequently be preserved, but may be working even better than usual. Out of numerous mechanisms of defense in schizophrenia projection, identification, projective identification, splitting, denial and regression are especially important. Moreover, psychotic patients frequently show certain symptoms that are related to very personal experiences. They can often be recognized quite easily as defence mechanisms. Countertransference is of great importance when treating such patients. Three of these numerous phenomenous are mentioned especially: anxiety, compassion, which may lead to identification, and the incapacity to accept the limit of therapeutic measures. The author is convinced that the so-called "psychodynamic" and "biological" psychiatry are not in opposition. Splitting them is not justified because according to the different stages of illness treatment with drugs as well as with different psychotherapeutic methods, even with psychoanalytical ones and social rehabilitation, are necessary. The etiology of schizophrenic psychosis cannot be explained with psychoanalysis either. Yet, the knowledge of psychodynamic processes can contribute essentially to understanding the illness and treating the patient. The compliance accomplished thereby can improve the quality of life of the patient and possibly for the therapist too.

Ego↗
PubMed1990

Difficult patients in extended psychiatric hospitalization: a research perspective on the patient, staff and team.

A series of publications has emerged from a comprehensive research project on difficulties in extended psychiatric hospital treatment, each of which describes factors that may influence difficulty: staff perceptions, difficult patient profiles, countertransference, intrapsychic features, organic brain impairment, problematic areas of treatment. This paper is intended to provide an overview and clinical integration of those diverse findings and an application of the findings to clinical conceptualization. The research supplements existing knowledge about treatment difficulty and countertransference in dyads by providing information about how such phenomena are influenced by clinical teams, by professional roles or disciplines, and by the treatment delivery system. Finally, I will describe future issues, questions and research efforts that are generated by these findings.

Dangerous Behavior↗
PubMed2000

"Where work is play for mortal stakes": the good hour in child analysis.

To explore the concept of the "good hour" in child analysis I discuss an hour in the analysis of a six-and-a-half-year-old girl. Elements of this hour include a palpable therapeutic alliance, affective immediacy, surprise, and discovery, oscillating therapeutic action of action, play, and verbalization, creative accessibility to the unconscious, the transference, the countertransference, and a capacity to work with conflict, defense, and fantasy. These qualities are similar to those described by Kris for adult analysis over forty years ago. The present hour, however, illustrates greater emphasis on affect rather than drive, the therapeutic action of play in the analytic setting, and the transformative importance of the relationship. In addition, the hour highlights a greater focus on communication by action and enactment, the highly informative uses of the countertransference, and the co-creation of the analytic process.

Child↗
PubMedDate not supplied

Borderlines: problems of self and object separation.

The borderline has deficiencies in the capacity to maintain stable self and object representations and in establishing 'emotional separateness' from others. In order to create and maintain a 'propitious treatment situation' and a 'therapeutic alliance' the therapist must work with unusual sensitivity and repetitiveness on the ground rules of the therapeutic environment. Explicit clarifications of the therapist's usual constructive attitudes, as a caring, responsive, neutral and real person must be continuously emphasized. The intense psychotic transference potential that leads to therapeutic complications and disruptions can be worked through, if recognized early, through countertransference clues, acceptance of positive aspects of the countertransference and technical moves that enhance the patient's capacity for individuation and separation, all this within the framework of a structured and consistent therapeutic situation. These assertions are illustrated by specific instances from treatment processes.

Adult↗
PubMed1985

Prognostic indicators in the psychotherapy of borderline patients.

Although diagnostic and therapeutic difficulties, including countertransference problems, in borderline patients make prognostic estimates hazardous, practical necessity often requires a prognostic judgment regarding treatability. This paper proposes a list of prognostic indicators in borderline patients which may be useful to the psychotherapist in the evaluation of treatability. Unfavorable prognostic indicators include history of brutalized early environment, severe behavior problems in childhood, antisocial behavior, addictions, egosyntonicity, superficial or highly disturbed relationships, marked narcissistic features, injurious social environment; and, in the course of therapy, strong negative reaction of the therapist toward the patient, and antisocial acting out. Suggesting a more favorable prognosis for psychotherapy are: nonspecific personality traits which may promote the therapeutic relationship (likeableness, warmth, reliability, or interest in people), and intact sublimatory outlets (talents, skills). In general, the quality of object relations, especially the therapist-patient relationship, including the countertransference, is crucial to prognosis. The unfavorable prognostic implications of certain atypical forms of anxiety, depression, and dependency, as well as anhedonia and abulia, are discussed. Borderline patients with infantile features probably have better prognosis than is generally recognized; with narcissistic features, a worse prognosis than generally recognized.

Adult↗
PubMed2000

Patient-therapist match: revelation or resistance?

Patient-therapist match is a relatively new yet frequently invoked concept within psychoanalysis. Despite Freud's appreciation of the influence of the analyst's past to his or her work within the analytic setting, psychoanalysts have historically held varied opinions about the degree to which the analyst's personality and conflicts affect the analytic process. As analysis was reconfigured as a two-person system, attention focused on the fit between patient and analyst. The literature on patient-therapist match is reviewed, and the conclusion reached that this intuitively appealing concept suffers from a lack of rigorous definition and operationalization. Many authors invoke match in ways that imply that it is real, static, external to the domain of analytic inquiry, and unaffected by analytic process. In its present form, the concept of patient-therapist match obstructs rather than facilitates analytic exploration and obscures rather than clarifies what happens between analyst and analysand in psychoanalysis. By suggesting that match exists as a reality outside the domain of transference and countertransference, analysts may overlook the importance of psychoanalytic technique in creating a sense of match. Analysts may attribute stalemated or limited analyses to a bad match, rather than tenaciously exploring the transference-countertransference configurations that remain at the heart of analytic work.

Humans↗
PubMed2001

Critical realism: distinguishing the psychological subjectivity of the analyst from epistemological subjectivism.

To clarify the concepts of critical realism, subjectivity, and subjectivism, distinctions are drawn among ontological subjectivism, moral subjectivity, psychological subjectivity, and epistemological subjectivism. Psychological subjectivity, including the ongoing affective life of the analyst, is an essential aspect of the analyst's response to the patient, and may either facilitate or distort an adequate observation of transference and countertransference dynamics and of the psychic reality of the patient. Subjectivism in current psychoanalytic literature involves an argument that there is an "irreducible" subjectivity in the analyst, who is bound to see things from an incorrigibly personal point of view, such that there is no substantial subject-object differentiation between analyst and patient. Issues of authoritarianism in the analyst, or of pathological certainty, should not be confused with the issues of epistemological objectivism. The concept of critical realism or scientific objectivism includes the essential idea that there is no pure knowledge, no complete knowledge, that often evidence is insufficient for knowledge of some aspect of nature, and that care must be to taken understand what is sufficient knowledge in a given area, in this case clinical psychoanalysis. The question is raised whether "projective identification" makes the sorting out of "what comes from whom" impossible. It is argued that when free association is sufficiently facilitated, when there are enough corrections of the distortions wrought by transference and countertransference, when defenses are analyzed, and when sufficient subject-object differentiation is recovered, the analyst can get to know enough of the patient's psychic reality for the therapeutic and scientific purposes of psychoanalysis.

Authoritarianism↗
PubMed1999

The patient's part in analytic process: the influence of the analyst's expectations.

The psychoanalyst's expectations of the patient are complex and crucial to the work of analysis. These expectations, operating at a level generally outside the consciousness of patient and analyst, are part of the "microstructure" of analysis, the interactional give-and-take that brings about change. The view taken here is that analytic process is necessarily interactive, as well as intrapsychic. In addition to transference-countertransference motivations, both parties to an analysis operate in a social context that prescribes a range of desired and undesired behavior. The analyst brings to the interaction professional analytic attitudes about how to listen and act, and a set of expectations of the patient. These attitudes and expectations modulate subjective reactions to the patient's transferentially driven actions, and influence the expression of countertransference. The mutative process of psychoanalysis involves the action of these attitudes and expectations on the patient, both in ways specific to individuals and in more general ways. Such expectations lie behind analytic tactics and, though not often written of, are part of the oral tradition of psychoanalysis. Here the expected patient role is described in terms of five bipolar continua: (1) reporting and editing; (2) transferring and containing; (3) thinking about oneself and thinking about the analyst; (4) regressing and listening/self-observing; (5) initiating trial action and mediating among inner states. The activity and thinking of the dyad move constantly along these continua. A clinical example from the beginning of an hour illustrates how these expectancies emerge in analytic work.

Adult↗